Author Question: The nurse is caring for a patient receiving heparin therapy. The nurse reviews the lab results and ... (Read 29 times)

Zulu123 · **on:** Jul 23, 2018

The nurse is caring for a patient receiving heparin therapy. The nurse reviews the lab results and notes that the platelet count has dropped to 100,000 mm3.

Further assessment of the patient reveals purple-tinged fingers and toes and tachypnea. The nurse should suspect __________________ and immediately ____________.
a. hemorrhage; administer vitamin K1
b. thrombocytopenia; discontinue heparin
c. massive pulmonary embolus; institute ventilator support
d. massive myocardial infarction; administer nitroglycerin and oxygen

Question 2

The nurse is providing care to a patient who has just undergone a procedure in which epidural anesthesia was used.

When the patient returned from the procedure, the nurse administered enoxaparin (Lovenox) 30 mg as ordered. Which of the following findings would warrant an immediate call to the prescriber if it occurred after enoxaparin administration?
a. The patient's pulse oximetry reading decreases from 99 to 96.
b. The patient complains of pain at the enoxaparin injection site.
c. The patient complains of numbness and tingling in the lower extremities.
d. The right dorsalis pedis pulse is +3, and the left dorsalis pedis pulse is +2.

adammoses97 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
Heparin-induced thrombocytopenia (HIT) is an immune-mediated disorder characterized by reduced platelet counts. Paradoxically, thrombotic events increase, which can lead to ischemic injury to limbs and pulmonary embolism. Heparin needs to be discontinued.
The patient is showing clinical manifestations of clotting rather than bleeding. Vitamin K is the antidote for warfarin (Coumadin) overdose.
Although tachypnea can occur with pulmonary embolism, no data support the need for institution of ventilatory support.
The signs and symptoms in the scenario are not consistent with a massive MI.

Answer to Question 2

ANS: C
LMW heparins can cause severe neurologic injury, including permanent paralysis, when given to a patient undergoing spinal or epidural anesthesia. Neurologic injury results from pressure on the spinal cord generated by epidural or spinal bleeding. Numbness and tingling in the lower extremities can be a sign a sign of this condition.
Although the patient's oxygen saturation is slightly decreased, it is still within normal limits.
Pain at the injection site can occur and does not warrant an immediate call to the prescriber.
A pulse of +2 is palpable, and a pulse of +3 is strong and easily palpable. Both findings are normal. No information indicates that the patient's pulse strength has changed.