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Question

Difficulty: HardReduction of Risk Potential

A practical nurse is caring for a client who had a total knee arthroplasty 48 hours ago. The client is prescribed subcutaneous enoxaparin daily for deep vein thrombosis prophylaxis and oral hydrocodone-acetaminophen as needed for pain. During the morning assessment, the client reports feeling "lightheaded and weak." The nurse collects the following data:

Clinical IndicatorCurrent ValuePrevious Day Baseline
Blood pressure100/62 mm Hg138/82 mm Hg
Heart rate114 beats/min84 beats/min
Hemoglobin8.4 g/dL10.6 g/dL
Platelet count185,000/mm³190,000/mm³

Based on these findings, which action should the practical nurse take first?

  1. Withhold the scheduled dose of enoxaparin and immediately notify the registered nurse.Answer
  2. B
    Administer the scheduled enoxaparin because the platelet count remains within the normal reference range.
  3. C
    Attribute the lightheadedness and vital signs to the opioid analgesic and reassess in one hour.
  4. D
    Delegate the unlicensed assistive personnel to assist the client to the bedside commode.

Answer

Withhold the scheduled dose of enoxaparin and immediately notify the registered nurse.
The client's clinical picture—a significant drop in hemoglobin combined with new-onset tachycardia, a decrease in baseline blood pressure, and lightheadedness—strongly suggests acute postoperative bleeding or early hemorrhagic shock. The practical nurse must prioritize safety by withholding the anticoagulant medication, which could exacerbate bleeding, and immediately escalating these critical findings to the registered nurse for provider notification and potential medical intervention.

Step-by-Step Solution

1
Analyze the client's vital signs and laboratory trends in the provided table.
Identified a significant drop in hemoglobin (2.2 g/dL decrease), accompanied by new-onset tachycardia (114 beats/min) and hypotension (100/62 mm Hg).
Comparing current data to baseline is essential for recognizing subtle or acute physiological changes.
2
Correlate the objective data with the client's subjective report of feeling lightheaded.
Recognized that these combined findings strongly indicate early hemorrhagic shock or active postoperative bleeding.
Connecting symptoms with vital sign trends determines the clinical severity of the situation.
3
Evaluate the safety of the scheduled medications based on the client's current status.
Determined that administering enoxaparin (an anticoagulant) is contraindicated in the presence of suspected active bleeding.
Administering high-risk medications without synthesizing the current clinical picture can lead to adverse client outcomes.
4
Select the safest, most immediate nursing action within the practical nurse scope of practice.
Concluded that the priority is to withhold the medication and escalate the critical findings to the registered nurse.
The PN must recognize complications and immediately escalate unstable clients to the RN for further assessment and provider notification.

Key Concept

Early recognition of hemorrhagic shock and critical escalation within the PN scope of practice.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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