A nurse is monitoring the laboratory values of a client who is receiving heparin. Which of the following values should the nurse report to the provider?

PT 11 seconds

APTT 50 seconds

Hematocrit 456

Platelets 300,000/mm²

Answer and Explanation

The Correct Answer is C

A.PT (Prothrombin Time) 11 seconds: The prothrombin time measures the extrinsic pathway of the coagulation cascade. A PT of 11 seconds is within the normal range, and it indicates that the extrinsic clotting pathway is functioning appropriately. There is no need to report this value.
B. APTT (Activated Partial Thromboplastin Time) 50 seconds: The APTT measures the intrinsic pathway of the coagulation cascade. A value of 50 seconds is prolonged and may suggest that the client is receiving an effective anticoagulant dose. However, the APTT target range can vary based on the specific therapeutic goal and the heparin protocol in use. It's essential to follow the healthcare provider's guidance on the target APTT range.
C. Hematocrit 456: The normal range for hematocrit is usually expressed as a percentage. A value of 456 is outside the normal range and likely represents an error or a misinterpretation. The nurse should verify this value, as an extremely high hematocrit could be indicative of an issue such as dehydration or an analytical error.
D. Platelets 300,000/mm²: A platelet count of 300,000/mm² is within the normal range. There is no need to report this value as it suggests a normal platelet count.

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Correct Answer is A

Explanation

A. Assess the client for adverse reactions:
After ensuring the client's safety and well-being, the nurse can then proceed with the other necessary actions, such as determining the factors that led to the omission, filing an incident report, and reporting the missed dosage to the client's provider. However, assessing the client for any immediate adverse reactions takes precedence to address any potential harm that may have resulted from the missed medication dose.
B. Determine factors that led to the omission:
This is the correct answer. Understanding the factors that led to the omission is crucial for preventing future errors. The nurse should assess if there were any system failures, distractions, or other factors contributing to the missed dose.However, patient's safety and wellbeing comes first.
C. File an Incident report:
Filing an incident report is an important step, but it should not be the first action. The nurse needs to address the immediate situation and assess the factors contributing to the omission first.
D. Report the missed dosage to the client's provider:
Reporting the missed dosage to the provider is an important step, but it should not be the first action. The nurse needs to address the immediate situation, assess the client, and determine factors leading to the omission before reporting to the provider.

A. Infiltration B. Extravasation C. Venous spasm D. Phlebitis

Correct Answer is D

Explanation

A. Infiltration:
Infiltration refers to the inadvertent administration of a non-vesicant solution into the surrounding tissue. It is characterized by swelling, pallor, and coolness at the infusion site, but redness and inflammation along the vein are not typical signs of infiltration.
B. Extravasation:
Extravasation occurs when a vesicant solution (a substance that can cause tissue damage) infiltrates into the surrounding tissue. It can cause tissue damage and necrosis. While inflammation is a concern with extravasation, it is not the primary sign, and redness may occur later.
C. Venous spasm:
Venous spasm involves the constriction of the blood vessel, leading to decreased blood flow. It is not typically associated with redness and inflammation along the vein.
D. Phlebitis:
This is the correct answer. Phlebitis refers to inflammation of a vein, and it is characterized by redness, warmth, and tenderness along the course of the vein. Phlebitis can be caused by various factors, including irritants in the infused solution, mechanical trauma, or infection.

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A nurse is monitoring the laboratory values of a client who is receiving heparin. Which of the following values should the nurse report to the provider?

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