An adult client is receiving a scheduled course of subcutaneous enoxaparin. During data collection, the client reports passing dark, tarry stools. The practical nurse notes that the client's latest laboratory results show a platelet count of , and current vital signs include a heart rate of and a blood pressure of . Which of the following is the priority action for the practical nurse?
- AAdminister the scheduled injection, as a decreased platelet count is an expected therapeutic effect of enoxaparin.
- Withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.Cevap
- CDecrease the medication to half the prescribed dose to mitigate the risk of severe gastrointestinal hemorrhage.
- DDocument the findings and recheck the vital signs in one hour, as the blood pressure is borderline normal.
Cevap
The correct action is to withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.
The correct answer demonstrates the practical nurse's responsibility to recognize critical pharmacological safety concerns and act strictly within their scope of practice. The client's dark, tarry stools, tachycardia, hypotension, and thrombocytopenia () are classic signs of gastrointestinal hemorrhage and a severe adverse reaction to enoxaparin. The absolute priority is to withhold the anticoagulant to prevent worsening the hemorrhage and to immediately alert the registered nurse so that emergency medical interventions can be initiated.
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Anahtar Kavram
Recognizing adverse effects of anticoagulants (active bleeding and thrombocytopenia) and applying appropriate LPN scope of practice actions.