Nurse Jordan, a seasoned member of the team, has been openly belittled by Nurse Taylor, a newer nurse. During handoffs, Nurse Taylor makes sarcastic remarks about Nurse Jordan's decisions, saying, "I can't believe you thought that was the right approach." This behavior creates a tense atmosphere and affects team dynamics. What type of behavior is Nurse Taylor exhibiting in this scenario?

A. Client develops ecchymosis at the venipuncture site. Minor bruising at venipuncture sites is a common and expected side effect of heparin therapy due to its anticoagulant effect. While the nurse should monitor for increased bruising, isolated ecchymosis at an IV site does not necessarily indicate excessive anticoagulation or require immediate provider notification.
B. PTT 70 seconds (control 25-40). Heparin therapy is adjusted based on the activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5 to 2.5 times the control value, which in this case would be approximately 60-100 seconds. A PTT of 70 seconds is within the therapeutic range, so it does not require urgent intervention.
C. Client develops hematuria. Hematuria is a sign of potential excessive anticoagulation or internal bleeding, which can be a serious complication of heparin therapy. This finding suggests that the client's coagulation status may need immediate reassessment, and the heparin infusion may require adjustment or reversal with protamine sulfate if necessary. The healthcare provider should be notified promptly.
D. Order for Coumadin 2.5 mg to begin today. It is common practice to start warfarin (Coumadin) while a client is on heparin therapy because warfarin takes several days to reach therapeutic levels. Heparin is typically continued until the INR reaches a therapeutic range. Therefore, this order does not require provider notification.

A. Repositioning in bed: While repositioning the client is important for comfort and preventing complications such as pressure ulcers, it is not the top priority immediately after a pneumonectomy. Proper positioning can help improve respiratory function, but ensuring the stability and function of chest drainage systems takes precedence in the immediate postoperative period.
B. Use of the incentive spirometer: Encouraging the use of an incentive spirometer is crucial for promoting lung expansion and preventing atelectasis. However, it is essential first to ensure that the client’s chest tube is functioning properly and that there are no complications from the surgery. While this intervention is important, it follows the need to assess the chest tube.
C. Application of antiembolism stockings: While applying antiembolism stockings is a good practice to prevent venous thromboembolism, it is not the highest priority in the immediate postoperative period. Other assessments and interventions, such as monitoring respiratory status and chest tube function, are more critical in this early stage after surgery.
D. Chest tube and pleura-vac assessment: This is the priority nursing intervention in the immediate postoperative period. After a pneumonectomy, monitoring the chest tube's placement, drainage output, and function is vital for ensuring that the pleural space is adequately drained and that there are no complications such as pneumothorax or hemothorax. This assessment is crucial for maintaining respiratory function and overall stability in the postoperative client.