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Difficulty: HardReduction of Risk Potential

A practical nurse is preparing to administer a scheduled dose of subcutaneous enoxaparin to a client who is two days postoperative following a left total knee arthroplasty. While reviewing the client's morning assessment data and electronic health record, which finding requires the nurse to withhold the medication and immediately escalate to the registered nurse?

  1. A
    A decrease in systolic blood pressure from 122 mm Hg122 \text{ mm Hg} to 108 mm Hg108 \text{ mm Hg} with a resting heart rate of 88 beats/minute88 \text{ beats/minute}.
  2. B
    An alert indicating that the client's identification barcode wristband was removed during morning hygiene care.
  3. C
    A client report of localized, throbbing incisional pain rated as a 55 on a 00-to-1010 numerical scale.
  4. A complete blood count indicating a platelet level of 42,000 /mm342,000 \text{ /mm}^3 (42×109 /L42 \times 10^9 \text{ /L}).Answer

Answer

The correct action is to withhold the medication due to the complete blood count indicating a platelet level of 42,000 /mm³ (42 × 10⁹ /L).
The correct answer identifies a critical laboratory value that directly contraindicates the prescribed medication. Enoxaparin is an anticoagulant. Administering this medication to a client with a platelet count of 42,000 /mm342,000 \text{ /mm}^3 (normal is 150,000150,000 to 400,000 /mm3400,000 \text{ /mm}^3) places the client at imminent risk for severe, potentially fatal hemorrhage. The practical nurse must prioritize risk reduction by holding the dose and immediately notifying the registered nurse or healthcare provider.

Step-by-Step Solution

1
Analyze the prescribed medication and its primary physiological mechanism.
Enoxaparin is a low-molecular-weight heparin used for anticoagulation to prevent deep vein thrombosis.
Understanding the drug's mechanism highlights its primary adverse effect: increased bleeding risk.
2
Evaluate the clinical significance of each assessment finding.
The platelet count of 42,000 /mm342,000 \text{ /mm}^3 is critically low (normal is 150,000150,000 to 400,000 /mm3400,000 \text{ /mm}^3).
Platelets are essential for blood clotting; severe thrombocytopenia creates an imminent bleeding risk.
3
Synthesize the findings to prioritize client safety and determine the required nursing action.
Administering an anticoagulant to a severely thrombocytopenic client is directly contraindicated.
The practical nurse must apply principles of risk reduction by holding the dose and immediately notifying the registered nurse.

Key Concept

Correlating critical laboratory values (thrombocytopenia) with pharmacological interventions (anticoagulants) to reduce the risk of severe complications.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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