A review of laboratory results reveals a 30% decrease in platelet count from baseline in a patient receiving intermittent intravenous heparin therapy. What nursing action is indicated?
1. Have the laboratory rerun this test.
2. Skip one dose of heparin and have a PT/PTT drawn.
3. Discuss these findings with the health care provider.
4. Dilute the next heparin dose in normal saline and administer over at least 5 minutes.
3
Rationale 1: There is no indication that this laboratory test is in error.
Rationale 2: Skipping a dose of heparin and drawing additional lab work is not sufficient therapy.
Rationale 3: These results may signify heparin-induced thrombocytopenia and should be discussed with the health care provider.
Rationale 4: Diluting the heparin and giving it slowly will not affect the platelet count.
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A client with urinary tract alterations has trouble concentrating the urine. The nurse should suspect that the client:
1. has a malfunctioning bladder. 2. might be experiencing low levels of antidiuretic hormone (ADH). 3. might have cancer of the bladder. 4. might have kidney stones.
When assessing a patient in the hospital setting, the nurse knows which statement to be true?
a. The patient will need a brief assessment at least every 4 hours. b. The patient will need a consistent, specialized examination every 8 hours that focuses on certain parameters. c. The patient will need a complete head-to-toe physical examination every 24 hours. d. Most patients require a minimal examination each shift unless they are in critical condition.
The nurse is providing home care for a 1-year-old girl who is technologically dependent. Which intervention will best support the family process?
A) Finding an integrated health program for the family B) Teaching modifications of the medical regimen for vacation C) Assessing family expectations for the special-needs child D) Creating schedules for therapies and interventions
The client's urine specific gravity is 1.018 . What is the nurse's best action?
A. Ask the client for a 24-hour recall of liquid intake. B. Document the finding as the only action. C. Obtain a specimen for culture. D. Notify the physician.