The nurse is administering SUBQ enoxaparin to a client following knee replacement surgery to prevent a deep vein thrombosis. Which laboratory result requires immediate action by the nurse?
Reference Range:
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Platelets [150,000 to 400,000/mm3 (150 to 400 x 10^9/L)]
Creatinine [0.5 to 1.1 mg/dL (44 to 97 μmol/L)]
Blood Urea Nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]
Platelet count of 100,000/mm3 (100 x 10^9/L).
Serum creatinine 1.0 mg/dL (88.4 μmol/L).
Blood urea nitrogen (BUN) 20 mg/dL (7.1 mmol/L).
Hematocrit 45% (0.45 volume fraction).
The Correct Answer is A
A. A platelet count of 100,000/mm3 indicates thrombocytopenia, which increases the risk of bleeding with enoxaparin and requires immediate action.
B. A serum creatinine level of 1.0 mg/dL is within the normal range and does not require immediate action.
C. A BUN level of 20 mg/dL is at the upper end of the normal range but does not typically require immediate action unless accompanied by other symptoms.
D. A hematocrit level of 45% is within the normal range and does not require immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. pH levels are not directly affected by calcium acetate and do not indicate the medication's effectiveness.
B. Calcium acetate is used to lower phosphate levels in patients with CKD, so a decrease in phosphate indicates that the medication is having the desired effect.
C. Potassium levels are not directly impacted by calcium acetate and do not reflect the medication’s effectiveness in managing phosphate levels.
D. Calcium levels are not the primary target of calcium acetate therapy; the focus is on reducing phosphate levels in CKD management.
Correct Answer is D
Explanation
A. Applying a telemetry monitor is not necessary unless there are specific concerns about the client's heart rhythm or additional monitoring requirements.
B. While assessing for orthostatic hypotension is important in general, the heart rate of 48 beats/minute is a critical finding that needs immediate attention.
C. Administering the dose without addressing the bradycardia could exacerbate the low heart rate, so monitoring alone is insufficient.
D. Withholding the dose and notifying the healthcare provider is appropriate due to the client's bradycardia (heart rate of 48 beats/minute), which is a significant concern with beta-blockers like labetalol.
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