The nurse is caring for a male patient diagnosed with a Pulmonary Embolism (PE) who has been receiving a heparin IV infusion for 12 hours. Which of the following labs would require the nurse to titrate the heparin drip down?

Hemoglobin 20 g/dL (reference range 13.5-18 g/dL)

Prothrombin time (PT) 10 seconds (reference range 12-15 seconds)

Activated Partial thromboplastin time (aPTT) 89 seconds (reference range 52.5-87.5 seconds)

Platelets 455,000/mm3 (reference range 150,000-400,000/mm3)

Answer and Explanation

The Correct Answer is C

A. Hemoglobin 20 g/dL (reference range 13.5-18 g/dL): Elevated hemoglobin indicates hemoconcentration or polycythemia but does not directly influence heparin dosing. While high hemoglobin may affect blood viscosity, it is not a parameter used to titrate anticoagulation therapy.

B. Prothrombin time (PT) 10 seconds (reference range 12-15 seconds): PT evaluates the extrinsic coagulation pathway and is primarily used to monitor warfarin therapy, not IV heparin. A PT of 10 seconds is slightly below normal, but it does not indicate the need to adjust heparin infusion rates.

C. Activated Partial thromboplastin time (aPTT) 89 seconds (reference range 52.5-87.5 seconds): The aPTT measures the intrinsic and common coagulation pathways and is the standard parameter for titrating IV heparin. An aPTT above the therapeutic range indicates an increased risk of bleeding, requiring the nurse to decrease the heparin infusion.

D. Platelets 455,000/mm3 (reference range 150,000-400,000/mm3): Elevated platelet count (thrombocytosis) does not necessitate adjustment of heparin dosing. Heparin-induced thrombocytopenia would warrant monitoring, but in this case, platelets are elevated rather than decreased, so no immediate titration is indicated.

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Correct Answer is D

Explanation

A. Reinsert the tube into the chest tube insertion site: Reinserting a chest tube that has become dislodged is outside the scope of nursing practice and risks introducing infection and causing further trauma. Re-insertion must be performed by a qualified provider using sterile technique under appropriate conditions.

B. Insert the end of the chest tube in a container of sterile water: Placing the end of a dislodged chest tube into sterile water is appropriate only if the tube has disconnected from the drainage system but remains in the patient’s chest. In this scenario, the tube is lying on the floor, indicating it has been removed from the patient, so this action is not appropriate.

C. Auscultate the lung sounds in bilateral lung fields: Assessing lung sounds is important, but it is not the first priority. When a chest tube becomes dislodged from the patient, there is an immediate risk of air entering the pleural space and causing a tension pneumothorax. The insertion site must be addressed before further assessment.

D. Apply a sterile dressing to the chest tube insertion site: The priority is to immediately cover the insertion site with a sterile occlusive dressing (often taped on three sides) to prevent air from entering the pleural cavity and causing a life-threatening tension pneumothorax. This intervention directly addresses the most immediate physiological threat.

A. Heart rate decreases from 76 to 58 beats/min B. Respiratory rate increases from 12 to 20 C. Blood pressure increased from 124/76 to 136/85 mmHg D. Oxygen saturation decreases from 100 to 96%

Correct Answer is A

Explanation

A. Heart rate decreases from 76 to 58 beats/min: A sudden drop in heart rate (bradycardia) during suctioning indicates vagal stimulation, which can compromise cardiac output and perfusion. Suctioning should be stopped immediately to prevent further hemodynamic instability and potential cardiac arrest.

B. Respiratory rate increases from 12 to 20: An increase in respiratory rate is a normal response to airway stimulation during suctioning. It reflects mild irritation or the body’s attempt to maintain oxygenation and does not require stopping the procedure if the patient remains stable otherwise.

C. Blood pressure increased from 124/76 to 136/85 mmHg: A slight increase in blood pressure can occur due to sympathetic stimulation during suctioning. This is typically transient and does not necessitate stopping the procedure unless the patient shows other signs of instability.

D. Oxygen saturation decreases from 100 to 96%: A minor drop in oxygen saturation during suctioning is common, especially if suctioning is brief. Oxygen supplementation and careful monitoring are appropriate, but the procedure does not need to be stopped unless desaturation is severe (<90%) or prolonged.

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The nurse is caring for a male patient diagnosed with a Pulmonary Embolism (PE) who has been receiving a heparin IV infusion for 12 hours. Which of the following labs would require the nurse to titrate the heparin drip down?

Nursing Test Bank

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