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
Explanation
Choice A reason:
Taking an antacid one hour after ranitidine is recommended because antacids can affect the absorption of H2 receptor blockers like ranitidine. Ranitidine works by reducing stomach acid production, whereas antacids neutralize existing acid. Taking the antacid too close to the ranitidine can reduce the effectiveness of the ranitidine by altering the stomach's pH balance and affecting its absorption.
Choice B reason:
Taking an antacid and ranitidine at the same time does not enhance their effect. In fact, this can interfere with the absorption and effectiveness of ranitidine. Antacids can increase the pH of the stomach, which may reduce the absorption of ranitidine, thus diminishing its acid-reducing effects.
Choice C reason:
Taking both medications at the same time before meals is not advisable for the same reason as above. The simultaneous administration can reduce the effectiveness of ranitidine, as the increased pH caused by the antacid can interfere with the absorption of the H2 receptor blocker, thereby not providing the intended therapeutic effect.
Choice D reason:
The patient can take both medications, but they should be timed correctly to ensure optimal effectiveness. Saying that the patient needs to be on one medication only is incorrect. Both medications can be used together, but the antacid should be taken after ranitidine to avoid any interaction that might impair the effectiveness of ranitidine.
Correct Answer is B
Explanation
Choice A reason:
Pulmonary embolism is not a typical complication of a peptic ulcer. While serious, pulmonary embolism is unrelated to the gastrointestinal tract and would not arise from ulceration of the stomach or duodenum. It is therefore not the correct answer to the question posed.
Choice B reason:
Bleeding is the primary clinical manifestation of greatest concern with a peptic ulcer. Ulcers can erode into blood vessels, leading to gastrointestinal hemorrhage, which may present as hematemesis (vomiting blood) or melena (black, tarry stools). Severe bleeding can result in hypovolemic shock and requires immediate medical intervention, such as endoscopic hemostasis, blood transfusions, or surgery. This makes bleeding the most critical concern among the options listed.
Choice C reason:
Bowel obstruction can occur as a complication of peptic ulcer disease but is less common compared to bleeding. It arises from scarring or swelling near the pylorus, leading to gastric outlet obstruction. While serious, it is not the most frequent or immediate concern in the context of peptic ulcers.
Choice D reason:
Hepatomegaly, or enlargement of the liver, is unrelated to peptic ulcer disease. This symptom is typically associated with liver conditions such as cirrhosis, hepatitis, or cancer, and does not result from ulcer pathology.
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