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
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.
You might also like to view...
A clinical nurse specialist is meeting one on one with staff nurses while they are working to discuss data about the evidence-based practice. This is known as:
a. academic detailing. b. champion coaching. c. individual instruction. d. professional mentoring.
The correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity, related to:
a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.
A nurse is watching a video that depicts a client and therapist interacting. The client is asked to say whatever comes to his mind. The nurse identifies this as which of the following?
A) Dream work B) Free association C) Gestalt therapy D) Classical conditioning
____________________ occurs when breathing is insufficient to sustain life.
Fill in the blank(s) with the appropriate word(s).