A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 80,000/uL. Which action will the nurse take first?
Ask the HCP to change the medication from heparin to enoxaparin (Lovenox).
Discontinuing the heparin infusion
Administering prescribed warfarin (Coumadin)
Preparing for platelet transfusion
The Correct Answer is B
Choice A reason: Asking the HCP to change the medication from heparin to enoxaparin (Lovenox) would not be the most appropriate action for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Enoxaparin, like heparin, is a low molecular weight heparin and can still cause HIT. Therefore, this action does not address the immediate need to stop the heparin infusion to prevent further reduction in platelet levels and manage the HIT effectively.
Choice B reason: Discontinuing the heparin infusion is the correct action for a nurse to take first when a patient is diagnosed with heparin-induced thrombocytopenia (HIT). The primary step in managing HIT is to stop all forms of heparin to prevent further platelet activation and decrease in platelet count. Discontinuing heparin helps to prevent thromboembolic complications associated with HIT. Once heparin is discontinued, the healthcare provider can evaluate alternative anticoagulation therapies that do not cross-react with heparin, such as direct thrombin inhibitors.
Choice C reason: Administering prescribed warfarin (Coumadin) is not appropriate at this stage for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Warfarin can initially lead to a hypercoagulable state, which increases the risk of thrombosis in patients with HIT. The immediate priority is to discontinue heparin, and warfarin should only be considered once platelet counts have recovered and the acute HIT has been managed.
Choice D reason: Preparing for platelet transfusion is not the first action to take for managing heparin-induced thrombocytopenia (HIT). Platelet transfusions are generally avoided in HIT as they can potentially worsen the thrombotic risk. The primary action should be to discontinue heparin and consider alternative anticoagulation therapies. Platelet transfusions may be reserved for cases where there is significant bleeding or invasive procedures are planned.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: "I need to shop for foods low in sodium and avoid adding salt to food." This statement is correct and indicates appropriate understanding. Patients with SIADH need to manage their sodium intake carefully to avoid exacerbating hyponatremia.
Choice B reason: "I need to limit my fluid intake." This statement indicates a misunderstanding. Patients with SIADH should actually increase their fluid intake to help dilute the excess antidiuretic hormone and reduce hyponatremia. Limiting fluid intake can worsen the condition.
Choice C reason: "I should eat foods high in potassium because diuretics cause potassium loss." This statement is incorrect in the context of SIADH. While potassium intake is important for patients on diuretics, it is not directly related to SIADH management. The focus should be on managing fluid and sodium levels.
Choice D reason: "I should weigh myself daily and report sudden weight loss or gain." This statement is correct and indicates appropriate understanding. Regular weight monitoring is important for patients with SIADH to detect fluid imbalances early.
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
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