A nurse is caring for a female client who has deep-vein thrombosis (DVT) and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb)

Exhibits

Using the client information provided, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.)

 

Rationale:

A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.

B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.

C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.

D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.

E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.

F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.

Rationale:
A. Prominent P waves: Hyperkalemia typically causes a decrease in P wave amplitude and can eventually lead to their disappearance, rather than making them more prominent. Prominent P waves are not characteristic of elevated potassium levels.

B. Narrowed QRS complexes: Hyperkalemia often leads to a widening, not narrowing, of the QRS complex as potassium levels rise. A narrowed QRS complex is not a hallmark finding in clients with elevated potassium.

C. Shortened PR intervals: Hyperkalemia is more commonly associated with prolonged PR intervals. A shortened PR interval is not typically seen in potassium imbalance and would be more relevant in other conduction abnormalities.

D. Peaked T waves: Tall, peaked T waves are the classic early ECG finding in hyperkalemia. They result from increased potassium altering myocardial repolarization and are often the first electrocardiographic sign of elevated serum potassium.