A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
INR 1.6
WBC 6,000/mm3
Hgb 16 g/dL
aPTT 90 seconds
The Correct Answer is D
Choice A rationale:
An INR of 1.6 is slightly elevated but does not necessarily warrant an incident report.
Choice B rationale:
A WBC count of 6,000/mm3 is within a normal range and would not warrant an incident report.
Choice C rationale:
A hemoglobin level of 16 g/dL is within a normal range and does not warrant an incident report.
Choice D rationale:
An aPTT of 90 seconds is significantly prolonged and may indicate excessive anticoagulation from the heparin administration. This could potentially be a safety concern and would warrant an incident report for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Increased fluid intake is not likely to change the color of urine and sweat caused by rifampin.
Choice B rationale:
Dialysis is not indicated for managing the red-orange discoloration caused by rifampin.
Choice C rationale:
Rifampin can affect liver function, but the red-orange discoloration is not primarily related to liver function.
Choice D rationale:
Red-orange discoloration of urine, sweat, and other body fluids is an expected side effect of rifampin and does not require any specific interventions.
Correct Answer is D
Explanation
Choice A rationale:
Peanuts are not directly related to influenza vaccine contraindications.
Choice B rationale:
Shellfish allergies are not directly related to influenza vaccine contraindications.
Choice C rationale:
Milk allergies are not directly related to influenza vaccine contraindications.
Choice D rationale:
Influenza vaccines are typically grown in eggs and may contain trace amounts of egg protein. A severe egg allergy can be a contraindication for receiving the influenza vaccine due to the risk of an allergic reaction.
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