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 re-veals 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
B
Heparin-induced thrombocytopenia (HIT) is an immune-mediated disorder characterized by re-duced platelet counts. Paradoxically, thrombotic events increase, which can lead to ischemic in-jury 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 patient is exhibiting ventricular tachycardia with an irregular rhythm. The nurse should expect which dysrhythmia as the cause of the ventricular tachycardia?
A) Atrial fibrillation B) Atrial flutter C) Premature ventricular complex D) Sinus bradycardia
The respondent superior law states:
a. nurses may be sued individually b. employers must cover liability insurance for the nurse c. nurses must carry liability insurance d. the hospital is responsible for nurses damage
Which of the following is the only reliable source for quantifying pain?
A) The nurse B) The pain assessment tool C) The physician D) The client
A patient is prescribed a fentanyl patch to administer 100 mcg/hour. The patient uses one patch for 72 hours and then is changed to an intravenous infusion of morphine 8 hours into the second patch
If the patient had been receiving the morphine intravenously, how many mg of the medication would the patient have received from wearing the patch? Record your answer rounding to the nearest whole number.