A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?
Partial thromboplastin time (PTT) 65 seconds
Hematocrit 45%
White blood cell count 8.000/mm3
Platelets
The Correct Answer is A
A. Partial thromboplastin time (PTT) 65 seconds: The normal PTT range is typically between 25 to 35 seconds for patients not on anticoagulants. For a patient receiving heparin therapy, the therapeutic PTT range is usually 1.5 to 2.5 times the normal value, which translates to approximately 60 to 100 seconds. A PTT of 65 seconds is at the lower end of the therapeutic range and may require adjustment in dosage or closer monitoring, especially if there are concerns about achieving adequate anticoagulation for the treatment of a pulmonary embolism. It is important to report this value to the provider.
B. Hematocrit 45%: A hematocrit of 45% is within the normal range for adult females (38% to 47%) and males (40% to 54%). This value does not indicate any immediate concern related to heparin therapy or the treatment of a pulmonary embolism.
C. White blood cell count 8.000/mm³: A white blood cell count of 8,000/mm³ is within the normal range (4,500 to 11,000/mm³) and does not indicate any infection or inflammatory process that requires immediate reporting.
D. Platelets: The specific platelet count value is not provided. However, heparin therapy can lead to thrombocytopenia (low platelet count), so if the platelet count is below 150,000/mm³, it should be reported to the provider. Without the specific value, it is not possible to determine if this requires reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The bulb-like system will stay in place permanently after your surgery.": A Jackson-Pratt drain is a temporary measure used to collect drainage from a surgical site. It is designed to be removed once the output decreases and the surgical site is healing properly, so it does not remain in place permanently.
B. "You will receive medication through this device.": The Jackson-Pratt drain is specifically for draining fluids from the surgical area and does not administer medication. Medications are typically given through separate methods, such as IV or oral administration.
C. "This drain minimizes the chance for bacteria to enter the surgical site.": While proper drainage can help reduce the risk of complications associated with fluid accumulation, the main purpose of the drain is to facilitate the removal of fluids rather than to directly minimize bacterial entry. Maintaining a clean and sterile technique when handling the drain is essential to prevent infection.
D. "It provides a way to remove drainage and blood from the surgical wound.": This accurately reflects the primary function of the Jackson-Pratt drain. It allows for continuous drainage of excess fluids and blood from the surgical site, helping to prevent complications such as hematomas or seromas and promoting better healing outcomes.
Correct Answer is B
Explanation
A. Clean the client's dentures with regular toothpaste: Regular toothpaste can be too abrasive for dentures and may cause scratches or damage. It is better to use a cleanser specifically designed for dentures to avoid harming the surface while effectively cleaning them.
B. Place the client's dentures on a washcloth in a sink: This is a proper action to take when cleaning dentures. Placing the dentures on a washcloth in the sink provides a cushioned surface to prevent them from breaking if they slip out of the nurse's hands. Additionally, it helps to prevent them from rolling around in the sink, which can lead to damage.
C. Rinse the client's dentures in hot water: Rinsing dentures in hot water can warp the material or alter the fit, potentially leading to discomfort or ineffective cleaning. It is recommended to rinse dentures with lukewarm or cool water instead to maintain their integrity.
D. Remove the client's dentures with a moist glove: While using gloves is important for maintaining hygiene, removing the client's dentures with moist gloves is not necessary. The dentures should be removed carefully with clean, dry hands or gloves, and moisture is not required for this process.
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