The patient receives heparin. During the morning assessment of the patient, the nurse notes that the patient's blood pressure and red blood cell (RBC) count are low. There is no evidence of bleeding on the bed linen or the patient's gown
What will the best assessment of this patient reveal?
1. The patient is dehydrated.
2. The patient may be bleeding internally.
3. The patient's activated partial thromboplastin time (aPTT) is too low.
4. The patient has probably formed some clots.
Correct Answer: 2
Rationale: A low blood pressure and red blood cell (RBC) count in the patient could indicate internal bleeding. Internal bleeding, not the formation of clots, is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not a low activated partial thromboplastin time (aPTT), is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not dehydration, is most likely responsible for the low blood pressure and red blood cell (RBC) count.
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