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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Omit over-the-counter medications from the at-home medication list:
Over-the-counter medications should be included in the medication reconciliation process to provide a comprehensive overview of all medications the client is taking. These can have interactions or implications for the client's overall health.
B. Include medications the client received in the acute setting but will no longer need after transfer:
Medications that the client will no longer need after transfer should be excluded from the reconciliation list to avoid confusion and unnecessary continuation of those medications.
C. Compare the current list of medications to medications the client will receive after transfer:
This is part of the medication reconciliation process. It is important to ensure continuity of care by comparing the current list of medications with the medications the client will receive after transfer. Any discrepancies or changes should be addressed.
D. Remove duplicate medications of different dosages from the reconciliation list:
This is the correct answer. Duplicate medications with different dosages can lead to confusion and errors. The reconciliation process involves identifying and resolving discrepancies, including duplicates, to ensure accuracy and safety in medication administration
Correct Answer is A
Explanation
A. Urticaria (hives): Urticaria is a manifestation of an allergic reaction, which can occur during a transfusion reaction. If the client develops urticaria, it suggests an allergic response, and epinephrine may be administered to manage severe allergic reactions.
B. Distended jugular vein: Distended jugular veins may be associated with fluid overload or cardiovascular issues, but it is not a typical indication for administering epinephrine during a blood transfusion reaction.
C. Bounding pulse: A bounding pulse may be associated with increased cardiac output but is not typically an indication for epinephrine administration during a blood transfusion reaction.
D. Confusion: Confusion is a neurological symptom and is not a typical indication for administering epinephrine during a blood transfusion reaction. Neurological symptoms may suggest other complications that need appropriate interventions.
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