A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis and has bloody stools. Which of the following laboratory values should the nurse report to the provider?

Platelets 200,000/mm3

RBC count 5.4 million/mm2

Hgb 14 g/dL

INR 5.2

Answer and Explanation

The Correct Answer is D

A.   Platelets within the normal range indicate appropriate clotting function and are not concerning in this scenario.
B.   Red blood cell (RBC) count within the normal range suggests normal oxygen-carrying capacity and is not directly related to the client's symptoms.
C.   Hemoglobin (Hgb) level within the normal range indicates adequate oxygen-carrying capacity and is not directly related to the client's symptoms.
D.   An international normalized ratio (INR) of 5.2 is significantly elevated and indicates that the client's blood is not clotting properly. This could be a result of excessive anticoagulation from heparin therapy, which may lead to bleeding complications such as bloody stools. Therefore, the nurse should report this finding to the provider for further evaluation and possible adjustment of the anticoagulant therapy.

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Correct Answer is B

Explanation

A. Incorrect. While living in a rural location may present challenges, cataract surgery typically does not require an interdisciplinary care conference unless there are significant complicating factors.
B. Correct. A client who has hemiparesis and lives alone likely requires coordination of care from multiple disciplines to address safety concerns, functional limitations, and support needs. C. Incorrect. While assistance with dressing supplies may require coordination with social services or financial assistance programs, it does not necessarily warrant an interdisciplinary care conference.
D. Incorrect. While medication administration instructions are important, they can typically be addressed by the nursing staff without requiring an interdisciplinary care conference.

A. "Call a shelter in another county." B. "Leave your partner immediately." C. "Keep a packed bag by your front door." D. “Rehearse your escape route." E. None F. None

Correct Answer is D

Explanation

Rationale for A: While contacting a shelter in another county might be a good long-term option, the client should prioritize preparing for an immediate, safe escape rather than focusing on geographic distance.

Rationale for B: Telling the client to leave immediately may not be feasible or safe. The client needs to be prepared with a well-thought-out plan, including knowing when and how to leave, based on the safest opportunity.

Rationale for C: Keeping a packed bag by the front door may alert the abuser and increase the risk of violence. Instead, the bag should be kept in a secure and hidden location to avoid raising suspicion.

Rationale for D: Rehearsing an escape route is a critical component of a safety plan. It ensures the client knows how to leave quickly and safely in case of an emergency, which is vital for their safety.

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A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis and has bloody stools. Which of the following laboratory values should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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