A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 80,000/uL. Which action will the nurse take first?

Ask the HCP to change the medication from heparin to enoxaparin (Lovenox).

Discontinuing the heparin infusion

Administering prescribed warfarin (Coumadin)

Preparing for platelet transfusion

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking the HCP to change the medication from heparin to enoxaparin (Lovenox) would not be the most appropriate action for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Enoxaparin, like heparin, is a low molecular weight heparin and can still cause HIT. Therefore, this action does not address the immediate need to stop the heparin infusion to prevent further reduction in platelet levels and manage the HIT effectively.
Choice B reason: Discontinuing the heparin infusion is the correct action for a nurse to take first when a patient is diagnosed with heparin-induced thrombocytopenia (HIT). The primary step in managing HIT is to stop all forms of heparin to prevent further platelet activation and decrease in platelet count. Discontinuing heparin helps to prevent thromboembolic complications associated with HIT. Once heparin is discontinued, the healthcare provider can evaluate alternative anticoagulation therapies that do not cross-react with heparin, such as direct thrombin inhibitors.
Choice C reason: Administering prescribed warfarin (Coumadin) is not appropriate at this stage for a patient diagnosed with heparin-induced thrombocytopenia (HIT). Warfarin can initially lead to a hypercoagulable state, which increases the risk of thrombosis in patients with HIT. The immediate priority is to discontinue heparin, and warfarin should only be considered once platelet counts have recovered and the acute HIT has been managed.
Choice D reason: Preparing for platelet transfusion is not the first action to take for managing heparin-induced thrombocytopenia (HIT). Platelet transfusions are generally avoided in HIT as they can potentially worsen the thrombotic risk. The primary action should be to discontinue heparin and consider alternative anticoagulation therapies. Platelet transfusions may be reserved for cases where there is significant bleeding or invasive procedures are planned.

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Correct Answer is D

Explanation

Choice A reason: Cardiac dysrhythmias are not the primary concern in a patient with acute cholecystitis. Although severe pain can lead to stress on the cardiovascular system, it is not the main priority in this scenario. Hypotension can be a concern due to dehydration from vomiting, but pain management is addressed more comprehensively under fluid and electrolyte balance and infection control.
Choice B reason: Wound dehiscence is not relevant in this case as the patient has not undergone surgery yet. Fluid and electrolyte imbalance and hypotension are important considerations due to the patient’s nausea and vomiting, but wound dehiscence does not apply to her current state of care.
Choice C reason: The inadequate diet is a consideration due to the patient's inability to eat or drink, and hypotension is a risk due to dehydration. However, wound dehiscence is still not relevant since the patient has not had a surgical procedure yet. Preventing an inadequate diet is part of the broader management but not the immediate priority.
Choice D reason: Infection, fluid and electrolyte imbalance, and pain are the most relevant concerns for a patient with acute cholecystitis. The nasogastric tube and IV fluids are vital for managing her dehydration and electrolyte imbalances. The patient's high pain level (9/10) indicates severe discomfort that must be managed effectively. Additionally, with the insertion of a nasogastric tube and the risk of cholecystitis-related complications, preventing infection is a key priority.

A. Weight loss. B. Begins to cry when he tells you he recently lost his wife. C. Hyperactive bowel sounds. D. 1+ pitting edema noted in bilateral lower extremities. E. Heart rate 124. F. Bounding radial pulses. G. Anxious and restless.

Correct Answer is ["A","C","E","F","G"]

Explanation

Choice A reason: Weight loss is indicative of hypermetabolism caused by excessive thyroid hormone production. The increased metabolic rate leads to higher energy consumption, resulting in unintentional weight loss even if the patient maintains or increases their food intake.
Choice B reason: Begins to cry when he tells you he recently lost his wife. Emotional responses, such as crying, can be associated with personal loss and grief but are not directly linked to hypermetabolism or excess thyroid hormone. This statement reflects the patient's emotional state rather than a physiological manifestation of hyperthyroidism.
Choice C reason: Hyperactive bowel sounds are a common manifestation of hypermetabolism due to hyperthyroidism. The increased metabolic rate accelerates gastrointestinal motility, resulting in hyperactive bowel sounds and sometimes diarrhea.
Choice D reason: 1+ pitting edema noted in bilateral lower extremities is related to fluid retention and heart failure rather than hypermetabolism. Edema is not a typical manifestation of hyperthyroidism and is more indicative of cardiovascular or renal issues.
Choice E reason: A heart rate of 124 (tachycardia) is a common finding in patients with hyperthyroidism. Excess thyroid hormones increase the heart rate and cardiac output, leading to symptoms such as palpitations and tachycardia.
Choice F reason: Bounding radial pulses are indicative of increased cardiac output and stroke volume, which are common in hyperthyroidism due to the hypermetabolic state induced by excess thyroid hormones. This leads to strong and forceful pulses.
Choice G reason: Anxious and restless behavior is a manifestation of the increased adrenergic activity associated with hyperthyroidism. Excess thyroid hormones stimulate the nervous system, leading to symptoms such as anxiety, restlessness, and irritability.

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A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 80,000/uL. Which action will the nurse take first?

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Naxlex Comprehensive Predictor Exams

Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:

Correct Answer is D

Explanation

Correct Answer is ["A","C","E","F","G"]

Explanation

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