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 C
Explanation
A. The Sims position is lying on the left side with the right knee and thigh drawn up with the left arm placed along the back. This position is typically used for rectal examinations and enemas, not for administering nasal drops.
B. The prone position is lying face down. This position is not suitable for administering nasal drops as it can be uncomfortable and may obstruct proper administration.
C. The supine position is lying flat on the back with the face upward. This position is ideal for administering nasal drops as it allows for easy access to the nostrils and facilitates proper instillation of the medication.
D. The orthopneic position is sitting upright and leaning forward, often with the arms supported on a table or pillows. This position is sometimes used by patients with respiratory distress but is not typically recommended for administering nasal drops.
Correct Answer is A
Explanation
A. Correct. Ampicillin is a penicillin antibiotic and is contraindicated in clients who are allergic to penicillin.
B. Incorrect. Erythromycin is not a penicillin antibiotic and can be an alternative for clients allergic to penicillin.
C. Incorrect. Cefazolin is a cephalosporin antibiotic and is not related to penicillin. It can be used as an alternative in clients allergic to penicillin.
D. Incorrect. Clindamycin is not related to penicillin and can be used as an alternative in clients allergic to penicillin.
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