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 B
Explanation
A. Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B. Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C. Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D. While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.
Correct Answer is D
Explanation
A. Incorrect. Nail growth typically decreases with age rather than increases, and it is not due to calcium deposits.
B. Incorrect. Sweating tends to decrease with age rather than increase due to changes in sweat gland activity.
C. Incorrect. Cardiac output generally decreases with age due to changes in the heart's structure and function, rather than increasing due to weakened heart valves.
D. Correct. Increased joint stiffness is an expected age-related change due to the loss of elasticity in joint cartilage, leading to conditions such as osteoarthritis, which commonly affects older adults.
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