A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

The nurse should first address the client's chest pain followed by the client's irregular heart rate.

Rationale:

Chest pain is the priority concern as it indicates an acute coronary event (ST-elevation myocardial infarction, STEMI). Immediate interventions such as oxygen, nitroglycerin, and pain management are required to reduce myocardial oxygen demand and prevent further cardiac damage.

Irregular heart rate must be addressed next, as tachycardia and arrhythmias can increase myocardial workload and worsen ischemia. Monitoring and possible antiarrhythmic interventions may be required to stabilize cardiac function.

Incorrect:

Troponin levels: Elevated troponin confirms myocardial injury but does not require immediate intervention; managing the ongoing ischemia is the priority.

Oxygen saturation: The client's oxygen saturation is 93% on room air, which is adequate. Oxygen therapy is not the first priority unless levels drop further.

Hyperlipidemia: While a cardiovascular risk factor, it is not an acute concern during an MI. Long-term management is necessary but not the immediate priority.

C-reactive protein: Elevated CRP indicates inflammation but does not require urgent intervention in the acute phase of MI.

The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.

Rationale:

Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.

Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.

Incorrect:

Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.

Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.

Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.