A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?
Hematocrit 45%
Platelets 74,000/mm3
Partial thromboplastin time (PTT) 65 seconds
White blood cell count 8,000/mm3
The Correct Answer is B
Choice A reason: Hematocrit 45% is not the correct data. Hematocrit is the percentage of red blood cells in the blood. The normal range for hematocrit is 37% to 47% for women and 42% to 52% for men. Hematocrit 45% is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or destruction of red blood cells.
Choice B reason: Platelets 74,000/mm3 is the correct data. Platelets are the blood cells that are responsible for clotting and preventing bleeding. The normal range for platelets is 150,000 to 400,000/mm3. Platelets 74,000/mm3 is below the normal range and indicates thrombocytopenia, which is a low platelet count. Thrombocytopenia is a serious complication of heparin therapy that can cause bleeding, bruising, and petechiae. The nurse should report this finding to the provider immediately and stop the heparin infusion.
Choice C reason: Partial thromboplastin time (PTT) 65 seconds is not the correct data. PTT is a blood test that measures the time it takes for the blood to clot. The normal range for PTT is 25 to 35 seconds. PTT 65 seconds is above the normal range and indicates that the blood is taking longer to clot. This is an expected effect of heparin therapy, as heparin is an anticoagulant that inhibits the formation of blood clots. The nurse should monitor the PTT and adjust the heparin dose according to the provider's orders and the protocol.
Choice D reason: White blood cell count 8,000/mm3 is not the correct data. White blood cells are the blood cells that are involved in the immune system and fight infections. The normal range for white blood cells is 4,500 to 11,000/mm3. White blood cell count 8,000/mm3 is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or function of white blood cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ataxia is not a manifestation of digoxin toxicity, as it does not affect the coordination or balance of the client. Ataxia may be caused by other factors, such as cerebellar disorders, alcohol intoxication, or medication interactions.
Choice B reason: Anorexia is a manifestation of digoxin toxicity, as it affects the appetite and digestion of the client. Anorexia may be accompanied by nausea, vomiting, or abdominal pain, which are also signs of digoxin toxicity. Anorexia may lead to weight loss, dehydration, or electrolyte imbalance, which can worsen the condition of the client.
Choice C reason: Photosensitivity is not a manifestation of digoxin toxicity, as it does not affect the skin or the eyes of the client. Photosensitivity may be caused by other factors, such as sun exposure, allergies, or medication interactions.
Choice D reason: Jaundice is not a manifestation of digoxin toxicity, as it does not affect the liver or the bilirubin level of the client. Jaundice may be caused by other factors, such as liver disease, gallstones, or hemolysis.
Correct Answer is B
Explanation
Choice A reason: Blood pressure 160/94 mm Hg is not a reason to withhold atenolol, as it is a beta-blocker that lowers blood pressure and reduces the workload of the heart. Atenolol is indicated for hypertension, angina, and arrhythmias. The nurse should administer atenolol as prescribed, unless the blood pressure is too low (hypotension).
Choice B reason: Heart rate 46/min is a reason to withhold atenolol, as it is a sign of bradycardia (slow heart rate), which can be a side effect of atenolol. Atenolol can decrease the heart rate by blocking the beta-1 receptors in the heart. The nurse should withhold atenolol if the heart rate is below 60 beats per minute or above 100 beats per minute, and report the finding to the provider.
Choice C reason: Oxygen saturation 95% is not a reason to withhold atenolol, as it is a normal value that indicates adequate oxygenation of the blood. Atenolol does not affect the oxygen saturation or the respiratory function. The nurse should monitor the oxygen saturation regularly, and report any signs of hypoxia (low oxygen level).
Choice D reason: Respiratory rate 18/min is not a reason to withhold atenolol, as it is a normal value that indicates normal breathing. Atenolol does not affect the respiratory rate or the respiratory function. The nurse should monitor the respiratory rate regularly, and report any signs of dyspnea (difficulty breathing).
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