A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 110 beats per minute and a blood pressure of 90/62 mm Hg. A stat CBC shows a platelet count of less than 50,000, which is a low platelet count. The previous platelet level was 375,000. The nurse will:
Hold the heparin and notify the provider
Request an order for vitamin K (phytonadione)
Request an order for a PTT test
Administer oxygen and notify the provider
The Correct Answer is A
Choice A reason:
Holding the heparin and notifying the provider is the appropriate action. The significant drop in platelet count suggests the possibility of heparin-induced thrombocytopenia (HIT), a serious complication of heparin therapy. Immediate discontinuation of heparin and further evaluation are necessary to manage this condition.
Choice B reason:
Requesting an order for vitamin K (phytonadione) is not appropriate in this scenario. Vitamin K is used to reverse the effects of warfarin, not heparin. The issue here is the potential for HIT, not an over-anticoagulation that requires vitamin K.
Choice C reason:
While requesting a PTT test is part of managing anticoagulation therapy, it is not the immediate priority in this case. The significant drop in platelet count is more concerning for HIT, which requires stopping heparin and notifying the provider for further evaluation.
Choice D reason:
Administering oxygen and notifying the provider is not specific to managing the issue of a significantly low platelet count in a patient on heparin. The primary concern here is the potential for HIT, which necessitates stopping the heparin.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D reason: The backup of pancreatic enzymes is the initial trigger for tissue damage in pancreatitis. When these enzymes become activated within the pancreas, they begin to digest pancreatic tissue, leading to inflammation and damage.
Choice A reason: Insulin toxicity is not a cause of tissue damage in pancreatitis. Insulin is a hormone that regulates blood sugar levels and does not play a role in the initial damage seen in pancreatitis.
Choice B reason: Autoimmune destruction of the pancreas is associated with conditions like type 1 diabetes, not pancreatitis. Pancreatitis is primarily caused by the premature activation of digestive enzymes within the pancreas.
Choice C reason: Hydrochloric acid reflux into the pancreatic duct is not a known cause of pancreatitis. The condition is related to the digestive enzymes produced by the pancreas itself, not stomach acid.
Correct Answer is C
Explanation
Choice C reason: Limiting pancreatic secretion is the primary reason for making patients with acute pancreatitis NPO and using gastric suctioning. By reducing the stimulation of the pancreas, the inflammation and autodigestion of pancreatic tissue can be minimized, aiding in the healing process.
Choice A reason: Preventing abdominal distention is a secondary benefit of making patients NPO, but it is not the primary reason for this intervention in acute pancreatitis.
Choice B reason: Preventing mechanical obstruction of the intestine is not the main goal of making patients NPO in acute pancreatitis. This condition primarily affects the pancreas, not the intestines.
Choice D reason: Preventing hyperglycemia associated with loss of insulin secretion is not the primary reason for making patients NPO in acute pancreatitis. While hyperglycemia can occur in severe cases, the main focus is on reducing pancreatic stimulation.
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