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 B

Explanation

Reasoning:

Choice A reason: Hemoglobin A is the normal adult hemoglobin, comprising two alpha and two beta chains. In sickle cell anemia, a mutation in the beta-globin gene produces hemoglobin S, not hemoglobin A, which does not cause sickling or the vaso-occlusive crises characteristic of the disease.

Choice B reason: Hemoglobin S is the abnormal hemoglobin in sickle cell anemia, resulting from a point mutation in the beta-globin gene. This causes red blood cells to sickle under stress, leading to hemolysis and vaso-occlusion, resulting in pain, organ damage, and the clinical features of sickle cell crises.

Choice C reason: Hemoglobin M is a rare hemoglobin variant causing methemoglobinemia, not sickle cell anemia. It results from mutations affecting heme iron, leading to cyanosis, not the sickling and vaso-occlusion seen with hemoglobin S, making it irrelevant to the client’s condition.

Choice D reason: Hemoglobin F, or fetal hemoglobin, is present in newborns and persists in small amounts in adults. In sickle cell anemia, increased hemoglobin F can reduce sickling, but it is not the cause. Hemoglobin S drives the disease’s pathophysiology, not hemoglobin F.

A. Neurologic function B. Strict intake and output C. Liver function tests D. Signs of dehydration E. Urine and blood chemistry

Correct Answer is ["A","B","E"]

Explanation

Reasoning:

Choice A reason: Neurologic function must be monitored in SIADH, as excessive water retention causes hyponatremia, which can lead to cerebral edema, seizures, or altered mental status. Tricyclic antidepressants may exacerbate SIADH by stimulating ADH release, making neurologic assessment critical to detect complications like confusion or seizures early.

Choice B reason: Strict intake and output monitoring is essential in SIADH to manage fluid overload. Excessive ADH causes water retention, and tracking fluid balance helps guide fluid restriction therapy to correct hyponatremia. This ensures the nurse can assess the effectiveness of interventions and prevent worsening fluid accumulation.

Choice C reason: Liver function tests are not directly relevant to SIADH management. While tricyclic antidepressants can affect liver function, SIADH primarily involves water retention and hyponatremia, not hepatic issues. Monitoring liver function is more relevant for drug toxicity, not the fluid and electrolyte imbalances of SIADH.

Choice D reason: Signs of dehydration are not a concern in SIADH, which causes water retention and fluid overload. Dehydration is more typical of diabetes insipidus, where water loss occurs. In SIADH, the focus is on preventing excessive fluid accumulation, making dehydration monitoring unnecessary in this context.

Choice E reason: Urine and blood chemistry, including sodium and osmolality, are critical in SIADH to monitor hyponatremia and fluid status. Elevated urine osmolality and low serum sodium indicate ongoing ADH excess. Regular monitoring guides fluid restriction and therapy to correct electrolyte imbalances and prevent complications like cerebral edema.

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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

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?

Correct Answer is B

Explanation

A client has been taking tricyclic antidepressants for many years for the treatment of depression. The client has developed SIADH and has been admitted to the acute care facility. What should the nurse carefully monitor when caring for this client? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

A client with a new diagnosis of ischemic stroke was treated in the ED with tissue plasminogen activator (t-PA) and then admitted to the ICU. In addition to closely monitoring the client’s cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a client with Cushing's syndrome?

A nurse cares for several clients with anemia and notes that all the clients have different types of anemia. What is the nurse’s best understanding of how anemias are classified, based on the deficiency of erythrocytes? (Select all that apply)

The nurse is planning care for a client diagnosed with immune thrombocytopenia. Which nursing intervention should be included in the plan of care?

A nurse is providing care to a client diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse understands that the primary problem involves which gland?

The nurse is caring for a 13-year-old diagnosed with sickle cell anemia. The client asks the nurse what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?