For which of the following situations should the nurse prepare for administration of protamine sulfate?
a. Patient on warfarin with INR of 4 and tarry stools
b. Patient on warfarin with PT of 12 seconds and bleeding from a laceration
c. Patient on a heparin drip with a PTT >120 seconds and active GI bleeding
d. Patient on a heparin drip with a PTT of 60 seconds and pink-tinged urine in the catheter bag
ANS: C
Because the PTT is well beyond the therapeutic range for a patient on a heparin drip (60 to 80 seconds) and the patient is actively bleeding, the nurse should anticipate administration of protamine sulfate to reverse the effects of the heparin.
Although the patient's INR may be within the therapeutic range for the specific problem requiring warfarin, the patient is experiencing signs of bleeding and may need to receive vitamin K (the antidote).
The patient's PT is normal, and normal clotting mechanisms will take over to stop the bleeding. No drug intervention is required.
The PTT is within the therapeutic range for a patient on a heparin drip. Although the urine is pink tinged, the nurse should consider the possibility of trauma from the catheter and should continue to observe for signs of gross hematuria before taking further action.
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