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 ["A","C","E"]
Explanation
A. Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). APs are trained to assist with activities of daily living, including bathing, under the supervision of nursing staff. The nurse should ensure that the AP is aware of any special considerations related to the client's recent amputation.
B. Review a low-sodium diet for a client who has hypertension: This task should not be delegated to APs, as it requires nursing knowledge and understanding to educate the client effectively. Discussing dietary modifications involves assessing the client's understanding and providing education, which falls under the nursing scope of practice.
C. Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable and the AP has been trained to assist clients with feeding. However, the nurse should assess the client's swallowing ability and any specific precautions related to the stroke before delegating this task.
D. Explain oral hygiene to a client receiving chemotherapy: This task should not be delegated to APs because it involves providing specific education and instructions regarding oral care, which requires nursing judgment and knowledge about the implications of chemotherapy on oral health.
E. Assist a client to ambulate using a gait belt: This task can be delegated to APs. Assisting with ambulation is within the scope of practice for APs, especially when proper techniques and safety measures, such as using a gait belt, are followed. The nurse should ensure that the AP has received appropriate training to assist with ambulation safely.
Correct Answer is B
Explanation
A. The vein appears cordlike: A cordlike appearance of the vein can indicate phlebitis or thrombosis rather than an infection. While this finding may be associated with complications related to an IV catheter, it does not specifically indicate an infection at the insertion site.
B. Purulent drainage is noted from the site: The presence of purulent drainage is a clear sign of infection. Purulent drainage typically indicates the accumulation of pus, which is a result of the body's immune response to infection. This finding aligns with the expectation of an infection at the IV catheter insertion site.
C. The client reports numbness at the site: Numbness is not a common symptom of infection. It may indicate nerve involvement or irritation, which could be related to the placement of the catheter, but it does not directly signify an infection at the insertion site.
D. Skin over the site is sloughing: Sloughing skin may indicate severe tissue damage or necrosis, which could occur in cases of severe infection, but it is not a typical finding in a localized infection at the insertion site. More commonly, an infection would present with redness, warmth, swelling, and possibly purulent drainage.
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