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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cleansing the perineal area from back to front can introduce bacteria from the rectum to the urinary tract, increasing the risk of infection. Front to back is the recommended direction for cleansing.
B. Washing the perineal area with povidone-iodine twice daily may be too frequent and could potentially irritate the area. Gentle cleansing with warm water is typically recommended.
C. Changing the perineal pad with each void helps to maintain cleanliness and prevent infection by reducing the buildup of moisture and bacteria.
D. Wiping the perineal area with a soft towel is appropriate for gentle cleansing but does not address the importance of changing the perineal pad regularly.
Correct Answer is A
Explanation
A. Verifying the identity of anyone who wants to remove the baby from the room is crucial for ensuring the security and safety of the newborn. This helps prevent unauthorized individuals from taking the baby without proper authorization from the parents or healthcare staff.
B. Leaving the baby unattended in the room while the parent walks in the hallway can pose a safety risk, as the newborn should always be under supervision to prevent accidents or unauthorized access.
C. Newborns typically wear identification bands on both wrists to ensure accurate identification and prevent mix-ups in the hospital setting. Placing identification bands on other body parts may lead to confusion.
D. Leaving the unit with the baby without notifying the nurse can compromise the security measures in place and may lead to confusion or concern among hospital staff regarding the whereabouts of the newborn. It's important to communicate with healthcare providers before leaving the unit with the baby.
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