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 C
Explanation
Choice A reason: Vitamin K is the antidote for warfarin, not heparin. Vitamin K reverses the effects of warfarin by increasing the synthesis of clotting factors in the liver.
Choice B reason: Glucagon is the antidote for insulin, not heparin. Glucagon increases the blood glucose level by stimulating the breakdown of glycogen in the liver.
Choice C reason: Protamine is the antidote for heparin, not vitamin K or glucagon. Protamine neutralizes the effects of heparin by binding to it and forming a stable complex.
Choice D reason: Iron is not an antidote for any anticoagulant. Iron is a mineral that is essential for the production of hemoglobin and red blood cells.
Correct Answer is B
Explanation
Choice A - Catheter Occlusion: This occurs when the catheter is blocked, preventing the flow of fluids or medication. It is usually indicated by difficulty in flushing the catheter or a slow drip rate¹. However, it does not typically cause a gurgling sound.
Choice B - (Catheter migration) is correct because when a central venous catheter (CVC) migrates from its original position, the tip can enter a smaller vein or a different location where turbulence occurs. This may cause the client to hear a gurgling or bubbling sound, especially during infusion or with position changes. Migration can happen due to coughing, movement, or changes in pressure, and it doesn’t necessarily involve the catheter being visibly out of place
Choice C - (Catheter dislodgment) is incorrect because dislodgment typically refers to the catheter being partially pulled out of the insertion site. This would be more likely to cause external signs like visible catheter movement or fluid leakage at the insertion site, rather than internal gurgling sounds. Gurgling is more associated with internal changes in catheter position, as seen with migration.
Choice D - Catheter Rupture: This is a break or tear in the catheter. It can cause serious complications, including infection and embolism. However, a gurgling sound is not a typical symptom of a catheter rupture¹.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today