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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason:
HIV can be transmitted through blood products. This mode of transmission occurs when contaminated blood, used in transfusions or other medical procedures, carries the virus to another person. It is one of the primary ways HIV spreads, especially before strict blood screening protocols were implemented.
Choice B reason:
Perinatal transmission refers to the transmission of HIV from a mother to her fetus during pregnancy, childbirth, or breastfeeding. This is a significant mode of transmission, particularly in regions with high HIV prevalence and limited access to antiretroviral therapy.
Choice C reason:
This choice is incorrect because HIV is not transmitted through airborne means. Unlike respiratory viruses, HIV requires direct contact with certain body fluids for transmission. Airborne transmission would imply that the virus could spread through the air, which is not the case with HIV.
Choice D reason:
Sexual transmission is a major route for HIV spread. The virus is present in bodily fluids such as semen, vaginal fluids, and rectal fluids. Unprotected sexual contact allows the virus to pass from one person to another, making this a crucial mode of HIV transmission.
Correct Answer is A
Explanation
Choice A reason:
An embolus is the term used to describe a detached blood clot or other material that travels through the bloodstream and can cause a blockage in a blood vessel. Emboli can be composed of blood clots, fat, air, or other substances, and they can lead to serious conditions like strokes or pulmonary embolisms when they obstruct blood flow.
Choice B reason:
A thrombus is a blood clot that forms in a blood vessel and remains at its site of origin. It does not refer to a clot that has detached and is traveling through the bloodstream. The distinction between thrombus and embolus is crucial in understanding and describing vascular conditions.
Choice C reason:
Thromboembolus is a term that combines thrombus and embolus, indicating that a thrombus has become an embolus. While accurate, the more precise and commonly used term for a detached blood clot is simply "embolus."
Choice D reason:
Infarction refers to tissue death due to a lack of blood supply, often caused by an embolus or thrombus blocking a blood vessel. It does not describe the detached blood clot itself but rather the result of its action.
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