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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Addison disease results from adrenal insufficiency, causing deficient cortisol and aldosterone production. This leads to symptoms like hypotension, hyponatremia, and hyperkalemia, opposite to the cortisol excess seen in Cushing syndrome, which involves weight gain, hypertension, and hyperglycemia due to elevated adrenal cortex activity.
Choice B reason: Hashimoto disease is an autoimmune thyroiditis causing hypothyroidism, with low thyroid hormone levels leading to fatigue, weight gain, and cold intolerance. It does not involve adrenal cortex cortisol excess, unlike Cushing syndrome, which is characterized by hypercortisolism and distinct metabolic and physical symptoms.
Choice C reason: Cushing syndrome is defined by excess free circulating cortisol from the adrenal cortex, due to pituitary tumors, adrenal hyperplasia, or exogenous steroids. This causes weight gain, moon face, hypertension, and hyperglycemia, reflecting cortisol’s effects on metabolism, fat distribution, and fluid balance, making it the correct disorder.
Choice D reason: Graves disease is an autoimmune condition causing hyperthyroidism, with excess thyroid hormone leading to weight loss, tachycardia, and heat intolerance. It does not involve adrenal cortex cortisol production, unlike Cushing syndrome, which is specifically related to hypercortisolism and its systemic metabolic effects.
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Thiazide diuretics reduce urine output in nephrogenic diabetes insipidus by increasing sodium excretion, which enhances water reabsorption indirectly. However, they are not the primary treatment for central diabetes insipidus, where ADH deficiency is the issue. Desmopressin, an ADH analog, directly addresses the hormonal deficiency, making thiazides less effective.
Choice B reason: Diabinese (chlorpropamide) is a sulfonylurea used for type 2 diabetes mellitus, not diabetes insipidus. It lowers blood glucose by stimulating insulin release, which is irrelevant to the water balance issue in diabetes insipidus caused by ADH deficiency. It does not address the underlying hormonal imbalance.
Choice C reason: Desmopressin (DDAVP) is a synthetic ADH analog used to treat central diabetes insipidus. It mimics ADH, promoting water reabsorption in the kidneys’ collecting ducts, reducing polyuria and thirst. This directly corrects the fluid imbalance caused by ADH deficiency, making it the primary and most effective treatment.
Choice D reason: Ibuprofen, a nonsteroidal anti-inflammatory drug, is used for pain and inflammation, not for fluid balance in diabetes insipidus. It has no effect on ADH or renal water reabsorption, making it irrelevant for treating the excessive urine output and dehydration associated with this condition.
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