A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis and has bloody stools. Which of the following laboratory values should the nurse report to the provider?

Platelets 200,000/mm3

RBC count 5.4 million/mm2

Hgb 14 g/dL

INR 5.2

Answer and Explanation

The Correct Answer is D

A.   Platelets within the normal range indicate appropriate clotting function and are not concerning in this scenario.
B.   Red blood cell (RBC) count within the normal range suggests normal oxygen-carrying capacity and is not directly related to the client's symptoms.
C.   Hemoglobin (Hgb) level within the normal range indicates adequate oxygen-carrying capacity and is not directly related to the client's symptoms.
D.   An international normalized ratio (INR) of 5.2 is significantly elevated and indicates that the client's blood is not clotting properly. This could be a result of excessive anticoagulation from heparin therapy, which may lead to bleeding complications such as bloody stools. Therefore, the nurse should report this finding to the provider for further evaluation and possible adjustment of the anticoagulant therapy.

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Correct Answer is D

Explanation

A. Anger is characterized by feelings of hostility and frustration, which may arise as the client acknowledges the reality of their situation.
B. Depression involves feelings of sadness, hopelessness, and despair, often occurring as the client comes to terms with the impending loss or changes associated with their condition.
C. Acceptance involves acknowledging and coming to terms with the reality of the situation without resistance or denial.
D. Denial is a defense mechanism where the client refuses to acknowledge the reality of their situation, such as the need for a lengthy recovery period after open heart surgery. The client's statement reflects denial, as they are minimizing the seriousness of the surgery and its impact on their recovery.

A. A client who has a head injury and whose pupils are fixed and dilated B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10 C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding D. A client who has diminished breath sounds and paradoxical chest movement

Correct Answer is D

Explanation

A client who has a head injury and whose pupils are fixed and dilated: This client likely has a severe head injury with signs of increased intracranial pressure, which requires urgent intervention. However, airway and breathing take precedence over neurological status in triage. B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10: While this client is in pain, dislocated shoulder is not immediately life-threatening in the context of a mass casualty situation.
C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding: Although this client has a significant laceration, it is not immediately life-threatening compared to compromised breathing.
D. A client who has diminished breath sounds and paradoxical chest movement: This client is likely experiencing a tension pneumothorax, a life-threatening condition that requires immediate intervention to decompress the chest and restore normal breathing.

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A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis and has bloody stools. Which of the following laboratory values should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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