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Difficulty: MediumReduction of Risk Potential

A client is receiving a continuous intravenous (IV) heparin infusion for the treatment of a deep vein thrombosis. The practical nurse is reviewing the client's clinical data. Which finding is the priority to report to the registered nurse (RN) immediately?

  1. A
    An activated partial thromboplastin time (aPTT) of 64 seconds
  2. B
    A platelet count of 190,000/mm³
  3. A heart rate of 118 beats per minute and blood pressure of 92/58 mm HgAnswer
  4. D
    A urine output of 120 mL over the last 3 hours

Answer

The finding that requires immediate reporting is the elevated heart rate combined with low blood pressure.
Tachycardia (heart rate of 118 beats per minute) and hypotension (blood pressure of 92/58 mm Hg) are classic early physiological signs of hypovolemia or shock. In a client receiving a continuous heparin infusion, these vital signs strongly suggest active internal hemorrhage. The practical nurse must immediately report these findings to the RN for rapid intervention, as bleeding is the most significant and potentially life-threatening adverse effect of anticoagulant therapy.

Step-by-Step Solution

1
Analyze the client's current treatment and associated physiological risks.
The client is on a continuous heparin infusion, which carries a high risk for bleeding complications, including concealed internal hemorrhage.
Identifying the primary risk factor helps prioritize assessment findings.
2
Evaluate the laboratory values provided in the clinical data.
The aPTT of 64 seconds is within the therapeutic target range for heparin. The platelet count of 190,000/mm³ is normal.
Normal or therapeutic laboratory results represent stable findings that do not require emergency escalation.
3
Evaluate the physiological measurements and vital signs.
The urine output is adequate at 40 mL/hr. However, the heart rate of 118 beats per minute and blood pressure of 92/58 mm Hg indicate a hypotensive and tachycardic state.
Adequate urine output indicates stable renal function, while abnormal vital signs point to a systemic issue.
4
Synthesize the findings to determine the priority nursing action.
The combination of tachycardia and hypotension in an anticoagulated client strongly suggests internal bleeding or hypovolemic shock, requiring immediate escalation to the RN.
Early recognition of shock signs is critical for client safety and risk reduction.

Key Concept

Monitoring for and identifying early signs of hemorrhage (such as tachycardia and hypotension) in clients receiving anticoagulant therapy is a critical component of risk reduction.
Estimated Time:1m 0s
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Reduction of Risk Potential

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