A patient who has been receiving a heparin infusion is diagnosed with heparin-induced thrombocytopenia (HIT). The nurse will anticipate which health care provider orders?

Administer iron supplements

Use saline for flushing IV lines and IV ports.

Give low-molecular-weight heparin (LMWH).

Administer platelet transfusions.

Answer and Explanation

The Correct Answer is B

A. Administer iron supplements: Iron supplementation addresses anemia due to iron deficiency but does not treat the underlying immune-mediated platelet destruction or thrombotic risk associated with heparin-induced thrombocytopenia (HIT). It is not a priority intervention in this condition.

B. Use saline for flushing IV lines and IV ports: In HIT, all heparin products, including heparin flushes, must be avoided to prevent further immune-mediated platelet activation and thrombosis. Saline flushes are used as a safe alternative to maintain IV patency without exposing the patient to additional heparin.

C. Give low-molecular-weight heparin (LMWH): LMWH is structurally similar to unfractionated heparin and can cross-react in patients with HIT, potentially worsening thrombocytopenia and thrombotic complications. It is contraindicated in this situation.

D. Administer platelet transfusions: Platelet transfusions are generally avoided in HIT because adding platelets can fuel thrombus formation, increasing the risk of life-threatening clotting events. They are reserved for severe bleeding or procedural needs only.

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Correct Answer is D

Explanation

A. History of chronic hypertension: While chronic hypertension can contribute to cerebrovascular disease, it is not a direct risk factor for developing a brain abscess. Brain abscesses typically arise from infectious sources rather than vascular conditions alone.

B. History of migraines: Migraines are a neurologic disorder characterized by recurrent headaches and vascular changes, but they do not predispose a patient to intracranial infections or abscess formation.

C. Recent tick removal: Ticks can transmit certain infections such as Lyme disease or tick-borne encephalitis, but these rarely lead directly to localized brain abscess formation. Tick removal alone is not a significant risk factor for bacterial brain abscess.

D. Recent head trauma with a skull fracture: Trauma that results in a skull fracture can create a direct pathway for bacteria to enter the brain tissue, increasing the risk of abscess formation. Open fractures, sinus involvement, or penetrating injuries provide a source for infection, making this the most significant contributing factor in the development of a brain abscess.

A. Measure hourly urine output. B. Monitor daily weight. C. Check skin turgor. D. Assess mucous membranes.

Correct Answer is A

Explanation

A. Measure hourly urine output: In the emergent phase of burn injury, massive fluid shifts occur due to increased capillary permeability and third spacing. Hourly urine output is the most reliable and immediate indicator of adequate renal perfusion and effective fluid resuscitation. Maintaining urine output at approximately 0.5 mL/kg/hr in adults reflects sufficient circulating volume and organ perfusion.

B. Monitor daily weight: Daily weight is useful for evaluating overall fluid balance trends but is not sensitive enough for rapid assessment during the emergent phase. Fluid shifts in major burns occur quickly, requiring more immediate indicators than once-daily measurements.

C. Check skin turgor: Skin turgor is not a reliable indicator of fluid status in burn patients because skin integrity is compromised and edema is common. Burn injury alters the elasticity and appearance of the skin, limiting the usefulness of this assessment.

D. Assess mucous membranes: Mucous membrane moisture may provide general information about hydration status, but it does not accurately reflect intravascular volume in patients with significant burn injuries. Rapid capillary leak and fluid shifts require more precise monitoring parameters such as urine output.

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A patient who has been receiving a heparin infusion is diagnosed with heparin-induced thrombocytopenia (HIT). The nurse will anticipate which health care provider orders?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with a brain abscess and is being prepared for treatment. The nurse is reviewing the patient's medical history. Which of the following factors is most likely to contribute to the development of a brain abscess in this patient?

Correct Answer is D

Explanation

During the emergent phase of burn care, which nursing action will be most useful in determining if a patient is receiving adequate fluid resuscitation?

Correct Answer is A

Explanation

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