A nurse is reviewing laboratory data from a client who has pulmonary embolism and is receiving IV heparin. Which of the following findings should the nurse report to the provider?
Platelets 74,000/mm3
White blood cell count 8,000/mm3
Partial thromboplastin time (PTT) 55 seconds
Hematocrit 45%
The Correct Answer is A
A. Platelets 74,000/mm: A platelet count of 74,000/mm³ is significantly lower than the normal range (typically 150,000 to 450,000/mm³). This could indicate heparin-induced thrombocytopenia (HIT), a serious adverse effect of heparin therapy where the immune system forms antibodies against heparin bound to platelet factor 4, leading to a decrease in platelets and increased risk of thrombosis. This is a critical finding and should be reported immediately to the provider for further evaluation and potential adjustment of the treatment plan.
B. White blood cell count 8,000/mm³: This is within the normal range (typically 4,000 to 11,000/mm³) and does not indicate an immediate problem related to heparin therapy or pulmonary embolism management.
C. Partial thromboplastin time (PTT) 55 seconds: While slightly elevated, this PTT is within the therapeutic range for a patient receiving IV heparin (typically 1.5 to 2.5 times the normal control value, or about 45 to 70 seconds). This indicates that the heparin is having the desired anticoagulant effect.
D. Hematocrit 45%: This is within the normal range for adults (typically 38-50% for men and 35-45% for women) and does not indicate an immediate concern related to heparin therapy or pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Easy bruising indicates the medication is effective: While some bruising is possible, excessive bruising doesn't necessarily mean the medication is working effectively. It could indicate excessive anticoagulation, requiring dose adjustments.
B. Inject the medication deep into the thigh muscle: Heparin is injected subcutaneously, targeting the fatty tissue layer just beneath the skin. Injecting into the muscle can be painful and decrease absorption.
C. Expect stools to become black and tarry: Black stools can be a sign of upper gastrointestinal bleeding, a potential but uncommon side effect. The nurse should instruct the client to report any black stools but not expect them as a normal occurrence.
D. Use a soft bristle toothbrush: This is important because heparin increases bleeding risk, and a soft-bristled toothbrush minimizes gum irritation and potential bleeding.
Correct Answer is D
Explanation
White Blood Cells (WBCs): WBCs are part of the immune system and play a role in fighting infections. However, they are not directly involved in hemostasis or clot formation.
Antibodies: Antibodies are proteins produced by the immune system to recognize and neutralize foreign substances (antigens). They do not directly participate in clot formation.
Red Blood Cells (RBCs): RBCs carry oxygen and carbon dioxide but are not directly involved in clotting. They do not adhere to the vessel wall during hemostasis.
Platelets: Platelets are small cell fragments in the blood. They clump together (aggregate) at the site of injury to form a temporary plug (platelet plug). Platelets adhere to the injured vessel wall and release chemicals that initiate clotting.
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