A 76-year-old patient is receiving IV heparin 5,000 units every 8 hours. An activated thromboplastin time (aPTT) is drawn 1 hour before the 8:00 AM dose; the aPTT is at 3.5 times the control value. What is the nurse's priority action?
A) Give a larger dose to increase the aPTT.
B) Give the dose as ordered and chart the results.
C) Check the patient's vital signs prior to administering the dose.
D) Hold the dose and call the result to the physician.
D
Feedback:
The therapeutic level of heparin is demonstrated by an activated partial thromboplastin time (aPTT) that is 1.5 to 3 times the control value. The patient's value is 3.5 times control, which indicates clotting time is a bit too delayed and the dosage will likely either be reduced or a dosage may be held according to the order received from the physician. It would be inappropriate to give two doses at once, give the dose and chart the results, or simply check the vital signs without holding the dose and calling the physician.
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