A 71-year-old male client with moderate to late-stage Parkinson disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. According to his wife, he needs assistance with ADLs only on days when his rigidity is worse, and walks short distances in the house using a walker. Which of the following actions would the nurse take? Select all that apply.

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.

Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.