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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. The contraceptive effect of a combination contraceptive transdermal patch does not continue for 6 months following discontinuation. Fertility typically returns soon after stopping the patch.
B. Correct. When starting a combination contraceptive transdermal patch, it is usually recommended to apply the first patch on the first day of the menstrual cycle or on the Sunday after the menstrual cycle starts. If applying it on the Sunday, the client should start on the seventh day of the menstrual cycle.
C. Incorrect. The patch should be applied to clean, dry, intact skin on the buttocks, abdomen, upper outer arm, or upper torso, but not specifically to the lower abdomen.
D. Incorrect. While headaches are a possible side effect of combination contraceptive methods, they are not universally experienced by all users, and they may occur at any point during use, not just during the first month.
Correct Answer is B
Explanation
A. Telling the client to ignore others minimizes their feelings and does not address the underlying issue of bullying or social discomfort.
B. Validating the client's feelings acknowledges their emotions and demonstrates empathy, which can help build trust and rapport with the client.
C. While it's important to address the client's needs, dismissing their concerns about social interactions may contribute to feelings of isolation and neglect.
D. Offering reassurance without addressing the client's current distress may invalidate their feelings and overlook the need for support and intervention in the present moment.
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