A patient receiving heparin therapy develops a platelet count of 120,000/mm3 (normal: 150,000-450,000) and presents with red and swollen legs. The nurse suspects Heparin-Induced thrombocytopenia. What is the nurse's priority action?

Continue heparin therapy and monitor platelet counts.

Discontinue heparin immediately and start an alternative anticoagulant,

Administer platelet transfusion to manage thrombocytopenia.

Administer intravenous fluids to prevent dehydration.

Answer and Explanation

The Correct Answer is B

A. Continue heparin therapy and monitor platelet counts: Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction in which antibodies form against the heparin–platelet factor 4 complex, leading to platelet activation and thrombosis. Continuing heparin can worsen platelet consumption and increase the risk of life-threatening thromboembolic events.

B. Discontinue heparin immediately and start an alternative anticoagulant: The priority intervention in suspected HIT is the immediate cessation of all heparin products to prevent further antibody-mediated platelet activation. Because HIT creates a prothrombotic state, an alternative non-heparin anticoagulant is initiated to reduce the risk of DVT or PE.

C. Administer platelet transfusion to manage thrombocytopenia: In HIT, thrombocytopenia results from platelet activation and consumption, not from decreased production. Transfusing platelets may exacerbate thrombosis by providing additional substrate for clot formation. Platelet transfusions are generally avoided unless there is significant active bleeding.

D. Administer intravenous fluids to prevent dehydration: While maintaining adequate hydration is important for overall circulatory stability, IV fluids do not address the immune-mediated platelet activation or thrombotic risk associated with HIT. The immediate threat is thrombosis, which requires stopping heparin and initiating alternative anticoagulation.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "An EEG can be used alone to determine if brain activity is still present in patients who are unresponsive.": EEG cannot be used in isolation to declare brain death because it may be affected by medications, metabolic disturbances, or hypothermia, and clinical assessment is required for a comprehensive evaluation.

B. "An EEG is not needed to determine brain death as clinical signs are sufficient.": While clinical criteria are central to brain death determination, EEG may be used as an ancillary test in certain situations, such as when confounding factors prevent full clinical assessment, to provide objective confirmation of electrical inactivity.

C. "The EEG will confirm brain death when no electrical activity is present in the brain.": EEG records cortical electrical activity, and the absence of detectable activity (electrocerebral silence) supports the diagnosis of brain death when combined with a complete clinical evaluation. This makes it a reliable confirmatory tool in specific cases.

D. "An EEG may show normal brain activity in patients who are close to brain death.": Patients nearing brain death generally exhibit severely diminished or absent cortical activity. Normal EEG findings would indicate preserved brain function and are inconsistent with imminent brain death.

A. Nuchal rigidity B. Sternal tenderness C. Bilateral wheezing D. Abdominal distention

Correct Answer is A

Explanation

A. Nuchal rigidity: Stiff neck, or nuchal rigidity, is a classic clinical sign of meningeal irritation and is strongly associated with bacterial meningitis. Inflammation of the meninges stimulates pain-sensitive structures, resulting in neck stiffness and resistance to flexion. This symptom, combined with fever, severe headache, and photophobia, supports the diagnosis.

B. Sternal tenderness: Sternal tenderness is not characteristic of bacterial meningitis. It is more commonly associated with trauma, costochondritis, or other musculoskeletal conditions and does not indicate meningeal inflammation.

C. Bilateral wheezing: Wheezing suggests lower airway obstruction or pulmonary involvement, such as asthma, bronchitis, or pneumonia. It is unrelated to the pathophysiology of bacterial meningitis and does not support the diagnosis.

D. Abdominal distention: Abdominal distention is not a symptom of bacterial meningitis. It is usually related to gastrointestinal conditions such as bowel obstruction, ileus, or ascites, and does not correlate with meningeal infection.

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A patient receiving heparin therapy develops a platelet count of 120,000/mm3 (normal: 150,000-450,000) and presents with red and swollen legs. The nurse suspects Heparin-Induced thrombocytopenia. What is the nurse's priority action?

Nursing Test Bank

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Correct Answer is C

Explanation

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