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Difficulty: HardReduction of Risk Potential

Morning rounds are being conducted on a medical unit for a client undergoing treatment for a deep vein thrombosis. The client is currently receiving a continuous infusion of unfractionated heparin. The client's most recent laboratory results reveal an activated partial thromboplastin time (aPTT) of 115 seconds. During data collection, the client's heart rate is noted at 102 beats per minute with a blood pressure of 98/60 mm Hg. What is the priority action for the practical nurse in this situation?

  1. A
    Record the laboratory values in the chart and observe the client for obvious signs of hematuria or melena.
  2. B
    Independently prepare and administer the prescribed intravenous push antidote to reverse the medication effects.
  3. Promptly alert the registered nurse regarding the client's coagulation values and current vital signs.Answer
  4. D
    Place the client in a supine position and plan to recheck the blood pressure in one hour.

Answer

Promptly alert the registered nurse regarding the client's coagulation values and current vital signs.
The client's aPTT of 115 seconds is critically elevated, placing them at severe risk for spontaneous bleeding. Furthermore, the client's mild tachycardia (102 beats per minute) and hypotension (98/60 mm Hg) are subtle but highly concerning indicators of early hemorrhagic shock. The practical nurse's priority is to immediately escalate these life-threatening findings to the registered nurse, who has the authority to halt the high-risk intravenous infusion and perform advanced interventions.

Step-by-Step Solution

1
Analyze the laboratory results.
The aPTT of 115 seconds is critically elevated beyond the therapeutic range (which is typically 1.5 to 2.5 times the normal control, up to about 70-80 seconds).
To determine if the continuous heparin infusion is maintaining safe and therapeutic anticoagulation.
2
Analyze the vital signs in the context of the laboratory data.
A heart rate of 102 beats per minute and a blood pressure of 98/60 mm Hg indicate mild tachycardia and hypotension, which are early signs of shock.
To identify if the client is actively experiencing a complication, such as internal hemorrhage, due to the toxic medication level.
3
Determine the appropriate scope of practice for intervention.
The practical nurse must immediately escalate these critical findings to the registered nurse.
To ensure immediate, safe intervention, as managing high-risk intravenous infusions and administering intravenous push antidotes are outside the practical nurse's scope.

Key Concept

Recognizing critical laboratory values and signs of shock, followed by immediate escalation to the registered nurse.
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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