To prevent deep vein thromboses following knee replacement surgery, an adult male client is receiving daily subcutaneous enoxaparin. Which laboratory result requires immediate action by the nurse?

Reference Range:
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Platelets [150,000 to 400,000/mm² (150 to 400 × 10^9/L)]
Creatinine [0.5 to 1.1 mg/dL (44 to 97 μmol/L)]
Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

Choice A: Printing an electrocardiogram strip is not a priority in this situation. The client is not responsive and has a low respiratory rate, which indicates a possible overdose of morphine. The nurse should focus on reversing the effects of the opioid and maintaining the client's airway and circulation.

Choice B: Providing rescue breaths with a manual ventilation bag is a correct and urgent action. It can supply oxygen to the client until naloxone takes effect and restore normal breathing.

Choice C: Giving naloxone 2 mg intravenously is a correct and urgent action. Naloxone is an opioid antagonist that can block the effects of morphine and reverse respiratory depression.

Choice D: This can help increase the patient’s oxygen levels, which may be low due to the decreased respiratory rate.

Choice E: Performing chest compressions is not a correct or urgent action. It is only indicated if the client has no pulse or signs of life. It can also cause harm if the client has a heartbeat.

Choice F: Calling for rapid response is a correct and urgent action. Rapid response is a team of health care professionals that can assist in emergency situations and provide advanced care.

Choice A reason: Using a Snellen chart to assess visual acuity is not a direct measure of the effectiveness of pilocarpine, which is used to lower intraocular pressure by constricting the pupil and increasing aqueous humor outflow. Visual acuity may be affected by other factors, such as refractive errors, cataracts, or macular degeneration.

Choice B reason: Checking the amount of drainage from each eye is not a relevant action for evaluating the effectiveness of pilocarpine, which does not affect tear production or drainage. Excessive or abnormal eye drainage may indicate an infection, allergy, or injury.

Choice C reason: Palpating the eyelids for decreased swelling is not a useful action for evaluating the effectiveness of pilocarpine, which does not cause or reduce eyelid swelling. Eyelid swelling may be caused by inflammation, infection, allergy, or trauma.

Choice D reason: Reviewing eye pressure measurements is the correct action for evaluating the effectiveness of pilocarpine, which is used to lower intraocular pressure in patients with open-angle glaucoma. High intraocular pressure can damage the optic nerve and cause vision loss. Pilocarpine reduces intraocular pressure by constricting the pupil and increasing aqueous humor outflow.