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Difficulty: EasyReduction of Risk Potential

During preparation for the morning medication administration, a practical nurse examines the electronic health record of a client prescribed subcutaneous heparin. The chart indicates that the client has a current platelet count of 45,000/mm345,000/\text{mm}^3 (45×109/L45 \times 10^9/\text{L}). Which of the following is the most appropriate action for the nurse to take?

  1. A
    Proceed with administering the injection and observe the client's skin for petechiae.
  2. B
    Direct the unlicensed assistive personnel to assess the client's body for any signs of active bleeding.
  3. Hold the scheduled dose and immediately inform the registered nurse about the finding.Answer
  4. D
    Document the laboratory value in the electronic health record and administer the medication as ordered.

Answer

Hold the scheduled dose and immediately inform the registered nurse about the finding.
The correct answer identifies that a platelet count of 45,000/mm345,000/\text{mm}^3 indicates severe thrombocytopenia (normal is 150,000150,000 to 400,000/mm3400,000/\text{mm}^3). Because heparin is an anticoagulant, giving this medication to a client who already lacks the platelets needed for blood clotting places them at an imminent risk for severe, spontaneous bleeding. The practical nurse must prioritize client safety by withholding the dose and immediately escalating the finding.

Step-by-Step Solution

1
Analyze the client's laboratory values against normal reference ranges.
The client's platelet count is 45,000/mm345,000/\text{mm}^3, which is significantly below the normal range of 150,000150,000 to 400,000/mm3400,000/\text{mm}^3.
Identifying abnormal labs is the first step in recognizing potential contraindications for medications.
2
Correlate the abnormal laboratory finding with the prescribed medication.
Heparin is an anticoagulant that prevents clotting; administering it to a client with severe thrombocytopenia creates an extreme risk for spontaneous hemorrhage.
Understanding the pharmacodynamics of a drug ensures safe administration and reduces risk potential.
3
Determine the safest nursing action within the practical nurse's scope of practice.
The nurse must withhold the medication to prevent harm and immediately escalate the critical lab value to the registered nurse or healthcare provider.
Protecting the client from harm and escalating critical findings are fundamental responsibilities of the practical nurse.

Key Concept

Reduction of risk potential by evaluating critical laboratory values prior to medication administration.
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Topics

Reduction of Risk Potential

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