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Difficulty: MediumReduction of Risk Potential

A licensed practical nurse reviews the electronic health records and physical assessment findings for multiple clients on a progressive care unit. To minimize the risk of adverse outcomes, which of the following clinical observations dictate an urgent report to the supervising registered nurse? Select all that apply.

  1. A client receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of 140 seconds140\text{ seconds}Answer
  2. A client who is 12 hours12\text{ hours} postoperative with a blood pressure of 88/52 mm Hg88/52\text{ mm Hg}, a resting heart rate of 118 beats/minute118\text{ beats/minute}, and new-onset restlessnessAnswer
  3. A client recovering from a cardiac catheterization who reports sudden, severe lower back pain and has a firm, tender flankAnswer
  4. D
    A client taking daily oral furosemide whose morning serum potassium level is 4.2 mEq/L4.2\text{ mEq/L}
  5. E
    A client receiving warfarin therapy for atrial fibrillation who has an International Normalized Ratio (INR) of 2.62.6
  6. F
    A client who is 24 hours24\text{ hours} post-appendectomy with a blood pressure of 116/74 mm Hg116/74\text{ mm Hg} and a heart rate of 78 beats/minute78\text{ beats/minute}

Answer

The observations that require urgent reporting include the critically elevated aPTT of 140 seconds, the signs of hypovolemic shock (hypotension, tachycardia, restlessness), and the indicators of a retroperitoneal hemorrhage (severe back pain, firm flank).
The correct selections represent life-threatening complications that require immediate intervention. An aPTT of 140 seconds is a critical panic value that necessitates stopping the heparin infusion to prevent severe hemorrhage. Hypotension combined with tachycardia and restlessness in a postoperative client are classic compensatory signs of hypovolemic shock. Sudden severe back pain and a firm, tender flank following a femoral catheterization strongly indicate retroperitoneal bleeding, a medical emergency.

Step-by-Step Solution

1
Evaluate the laboratory results for the clients receiving anticoagulants.
The aPTT of 140 seconds is critically high and poses a severe bleeding risk. The INR of 2.6 is within the safe, expected therapeutic range.
Identifying panic values allows for rapid intervention to prevent spontaneous hemorrhage.
2
Analyze the vital signs and physical assessments for the postoperative clients.
The client with a blood pressure of 88/52 mm Hg, a heart rate of 118 beats/minute, and restlessness is exhibiting early signs of shock. The client with a blood pressure of 116/74 mm Hg and a heart rate of 78 beats/minute is stable.
Borderline or deteriorating vital signs can indicate internal bleeding, which must be immediately escalated.
3
Assess the post-procedure client for localized complications.
New-onset severe back pain and a firm flank after a cardiac catheterization strongly suggest retroperitoneal bleeding.
Prompt recognition of arterial bleeding complications prevents hypovolemic shock and cardiovascular collapse.

Key Concept

Recognizing early signs of life-threatening complications, such as internal bleeding and critical laboratory values, is essential for the practical nurse to reduce client risk through immediate escalation.
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Topics

Reduction of Risk Potential

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