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Difficulty: MediumReduction of Risk Potential

While reviewing morning laboratory reports, a practical nurse (PN) notes that a client receiving a daily subcutaneous dose of enoxaparin has a platelet count of 65,000/mm365,000/\text{mm}^3 (65×109/L65 \times 10^9/\text{L}). Which action should the PN take first?

  1. Withhold the enoxaparin and notify the registered nurse of the laboratory results.Answer
  2. B
    Administer the enoxaparin as prescribed and monitor the client for bruising or bleeding.
  3. C
    Assess the client for mild tachycardia and hypotension before administering the medication.
  4. D
    Ask the registered nurse to administer the medication because it is a high-alert drug.

Answer

The practical nurse should withhold the scheduled enoxaparin and notify the registered nurse of the critically low platelet count.
The correct action is to withhold the scheduled medication and immediately notify the registered nurse. Enoxaparin is an anticoagulant that increases the risk of bleeding. A normal platelet count ranges from 150,000150,000 to 400,000/mm3400,000/\text{mm}^3. A count of 65,000/mm365,000/\text{mm}^3 is critically low (thrombocytopenia). Administering an anticoagulant to a client who already has a compromised ability to clot severely increases the risk of spontaneous hemorrhage. The practical nurse must recognize this critical value and intervene to prevent harm.

Step-by-Step Solution

1
Identify the purpose and physiological risks of the prescribed medication.
Enoxaparin is a low-molecular-weight heparin (anticoagulant) that prevents clot formation and inherently increases the risk of bleeding.
Understanding the medication's mechanism is required to evaluate safety parameters prior to administration.
2
Evaluate the client's laboratory results against normal reference ranges.
The client's platelet count is 65,000/mm365,000/\text{mm}^3, which is significantly below the normal range of 150,000150,000 to 400,000/mm3400,000/\text{mm}^3.
Platelets are essential for normal blood clotting, and low levels (thrombocytopenia) indicate an existing high bleeding risk.
3
Synthesize the findings to determine the appropriate nursing intervention.
Combining an anticoagulant with a critically low platelet count is unsafe. The medication must be withheld and the clinical finding escalated to the registered nurse.
The practical nurse must take immediate, proactive action to reduce the client's risk of severe hemorrhage.

Key Concept

Recognizing critical laboratory values (such as severe thrombocytopenia) and appropriately withholding contraindicated medications to reduce the risk of client injury.
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Topics

Reduction of Risk Potential

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