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 B
Explanation
Choice A reason:
Hepatocellular jaundice occurs due to damage or dysfunction of the liver cells (hepatocytes). This type of jaundice is associated with liver diseases such as hepatitis or cirrhosis, where the liver cannot effectively process bilirubin. It is not directly related to increased red blood cell breakdown but rather to the liver’s inability to handle bilirubin.
Choice B reason:
Hemolytic jaundice results from an increased breakdown of red blood cells, leading to a higher production of bilirubin, which the liver cannot clear fast enough. This condition causes an overload of bilirubin in the blood, resulting in jaundice. Hemolytic jaundice is typically seen in conditions such as hemolytic anemia, where red blood cell destruction exceeds the liver's ability to process and excrete bilirubin.
Choice C reason:
Obstructive jaundice is caused by a blockage in the bile ducts, preventing bilirubin from being excreted into the digestive system. This blockage can result from gallstones, tumors, or strictures. It is not related to the increased breakdown of red blood cells but rather to the obstruction of bile flow, leading to bilirubin buildup in the liver and subsequently in the blood.
Choice D reason:
Metabolic jaundice results from metabolic disorders that affect bilirubin processing or liver function. These disorders can lead to abnormalities in bilirubin metabolism, but they are not directly caused by increased red blood cell breakdown. Metabolic jaundice is less common than other forms and typically involves inherited conditions affecting bilirubin conjugation and excretion.
Correct Answer is B
Explanation
Choice B reason: Cirrhosis of the liver is the most likely cause of portal hypertension. Cirrhosis leads to scarring and fibrosis of the liver tissue, which obstructs blood flow through the liver and increases pressure in the portal vein, resulting in portal hypertension.
Choice A reason: Left ventricular failure is not a common cause of portal hypertension. It primarily affects the heart and can lead to pulmonary congestion and systemic edema, but not portal hypertension.
Choice C reason: Thrombosis in the spleen can contribute to portal hypertension, but it is not the most common cause. Cirrhosis of the liver is a more prevalent and significant cause of this condition.
Choice D reason: Renal stenosis affects the blood vessels supplying the kidneys and is not related to portal hypertension. It can lead to hypertension, but not specifically portal hypertension.
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