A client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client’s PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Consult with the health care provider about discontinuing heparin

Increase the heparin infusion by 100 units per hour

Begin treatment with the prescribed warfarin (Coumadin)

Continue with the present infusion rate of heparin

Answer and Explanation

The Correct Answer is A

Reasoning:

Choice A reason: Consulting the provider about discontinuing heparin is critical, as the client’s laboratory findings show a significant platelet drop (170,000 to 70,000/mm3), suggesting heparin-induced thrombocytopenia (HIT). HIT involves immune-mediated platelet destruction, increasing thrombosis risk. Stopping heparin prevents further platelet decline and thrombotic complications, making this the most urgent action.

Choice B reason: Increasing the heparin infusion is dangerous, as the platelet drop suggests HIT, where heparin triggers platelet activation and clotting. Further heparin administration could worsen thrombocytopenia and increase thrombosis risk, leading to severe complications like pulmonary embolism or stroke, making this action contraindicated.

Choice C reason: Beginning warfarin is inappropriate without addressing the platelet drop, likely due to HIT. Warfarin does not reverse thrombocytopenia and may increase bleeding risk in a thrombocytopenic patient. Heparin must be stopped first, and alternative anticoagulants considered, making warfarin initiation premature and risky.

Choice D reason: Continuing the current heparin rate is unsafe, as the significant platelet decline indicates possible HIT. Maintaining heparin could exacerbate platelet destruction and thrombosis risk, leading to life-threatening complications. Consulting the provider to discontinue heparin and investigate HIT is the priority to ensure patient safety.

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Correct Answer is A

Explanation

Reasoning:

Choice A reason: Strict vegetarians are at risk for megaloblastic anemia due to vitamin B12 deficiency, as B12 is primarily found in animal products. B12 deficiency impairs DNA synthesis, causing macrocytic anemia and symptoms like fatigue and neurological issues, a significant concern in vegan diets without supplementation.

Choice B reason: Sickle cell anemia is an inherited disorder caused by a hemoglobin S mutation, not dietary factors like vegetarianism. It leads to hemolytic anemia and vaso-occlusive crises, unrelated to nutritional deficiencies, making it an unlikely risk for a vegetarian client without genetic predisposition.

Choice C reason: Iron deficiency anemia is possible in vegetarians due to lower bioavailability of non-heme iron from plant sources, but B12 deficiency is a more specific risk in strict vegetarians, as animal products are the primary B12 source. Iron supplements or fortified foods can mitigate this risk.

Choice D reason: Aplastic anemia results from bone marrow failure, not dietary deficiencies. It causes pancytopenia and is unrelated to vegetarianism, which primarily risks nutritional anemias like B12 or iron deficiency. The client’s diet suggests a nutrient-specific issue, not bone marrow suppression.

A. Excessive thirst B. Low urine output C. Weight gain D. Excessive activities

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Excessive thirst, or polydipsia, is a hallmark of diabetes insipidus. ADH deficiency leads to excessive water loss through dilute urine, causing dehydration. This triggers the thirst mechanism to compensate for fluid loss, prompting increased water intake to maintain hydration, a key clinical feature of this condition.

Choice B reason: Low urine output, or oliguria, is not associated with diabetes insipidus. This condition causes polyuria due to impaired water reabsorption from ADH deficiency, leading to large volumes of dilute urine. Low urine output is more typical of conditions like acute kidney injury or SIADH.

Choice C reason: Weight gain is not a feature of diabetes insipidus. The condition leads to water loss and dehydration, often causing weight loss due to reduced fluid volume. Weight gain might occur in conditions like SIADH, where water retention dilutes sodium and increases body fluid content.

Choice D reason: Excessive activities are not a clinical manifestation of diabetes insipidus. This condition primarily affects fluid balance, causing polyuria and polydipsia. Increased activity levels are not linked to ADH deficiency, and patients may experience fatigue due to dehydration, not heightened physical activity.

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A client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client’s PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is a strict vegetarian. What type of anemia is the nurse aware that this client is at risk for?

Correct Answer is A

Explanation

Which is a clinical manifestation of diabetes insipidus?

Correct Answer is A

Explanation

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

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A client is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the client will experience?

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