During a bedside assessment, a nurse evaluates a client undergoing continuous intravenous … — NCLEX-RN

During a bedside assessment, a nurse evaluates a client undergoing continuous intravenous heparin therapy for a pulmonary embolism. The client's most recent activated partial thromboplastin time (aPTT) is $105$ seconds. The latest arterial blood gas (ABG) results on $2$ L/min oxygen via nasal cannula are: pH $7.38$ , $PaCO_2$ $42$ mm Hg, and $PaO_2$ $88$ mm Hg. The client suddenly reports a new, severe throbbing headache and blurred vision. Which action should the nurse take first?

A
Lower the head of the bed to a flat, supine position to optimize cerebral blood flow.
B
Monitor for a narrowing pulse pressure and tachycardia as early indicators of hemorrhagic shock.
Stop the continuous intravenous heparin infusion immediately.Answer
D
Increase the oxygen flow rate to $4$ L/min via nasal cannula to correct an uncompensated respiratory acidosis.

Answer

The correct action is to stop the continuous intravenous heparin infusion immediately.

The client is exhibiting classic signs of an intracranial hemorrhage (sudden severe headache and blurred vision) in the setting of a supratherapeutic aPTT. An aPTT of

105

seconds is significantly above the therapeutic range, indicating a severe bleeding risk. The most immediate priority is to stop the heparin infusion to prevent further life-threatening bleeding into the brain.

Step-by-Step Solution

Evaluate the aPTT laboratory value.

An aPTT of 105 seconds is significantly above the therapeutic range (usually 1.5 to 2.5 times the normal baseline), indicating profound anticoagulation and a severe risk for bleeding.

Understanding the bleeding risk associated with the current medication therapy establishes the client's baseline vulnerability.

Analyze the client's new clinical symptoms.

The sudden onset of a severe, throbbing headache and blurred vision strongly suggests increased intracranial pressure secondary to an intracranial hemorrhage.

Connecting supratherapeutic anticoagulation with acute neurological changes identifies a life-threatening procedural complication.

Determine the priority nursing intervention.

The continuous heparin infusion must be stopped immediately.

Removing the offending pharmacological agent is the most critical first step to prevent further catastrophic bleeding before notifying the provider and anticipating a head CT scan.

Key Concept

Prioritization and complication management in anticoagulant therapy

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic