A nurse on a medical-surgical unit is reviewing the morning laboratory results for four as… — NCLEX-RN

A nurse on a medical-surgical unit is reviewing the morning laboratory results for four assigned clients. To reduce the risk of a life-threatening complication, which client's result requires the most immediate intervention?

A client receiving a continuous intravenous heparin infusion who has a platelet count of $42,000/\text{mm}^3$ ( $42 \times 10^9/\text{L}$ ).Cevap
B
A client with severe chronic obstructive pulmonary disease (COPD) who has an arterial blood gas PaCO $_2$ of $54 \text{ mm Hg}$ .
C
A client who is two days postoperative following an open appendectomy with a white blood cell count of $12,000/\text{mm}^3$ ( $12.0 \times 10^9/\text{L}$ ).
D
A client prescribed daily oral furosemide for heart failure who has a serum potassium level of $4.2 \text{ mEq/L}$ ( $4.2 \text{ mmol/L}$ ).

Cevap

The client receiving intravenous heparin with a platelet count of

42,000/\text{mm}^3

A platelet count of

42,000/\text{mm}^3

(normal is

150,000

400,000/\text{mm}^3

) in a client receiving an intravenous anticoagulant is critically low. This places the client at imminent risk for spontaneous, severe hemorrhage or indicates the development of Heparin-Induced Thrombocytopenia (HIT). The nurse must immediately stop the infusion and notify the provider to reduce the risk of a fatal bleeding event.

Adım Adım Çözüm

Analyze the normal reference ranges for the provided laboratory values.

Normal platelets:

150,000

400,000/\text{mm}^3

. Normal PaCO

_2

35

45 \text{ mm Hg}

. Normal WBC:

5,000

10,000/\text{mm}^3

. Normal Potassium:

3.5

5.0 \text{ mEq/L}

Establishing baseline normal values is required before identifying abnormalities.

Evaluate the clinical context for each abnormal finding.

The COPD client's elevated PaCO

_2

is an expected chronic condition. The postoperative client's slightly elevated WBC is expected inflammation. The client on heparin has critically low platelets.

Context determines whether an abnormal value is an expected chronic state, a normal physiological response, or an acute emergency.

Prioritize the finding that poses the most immediate, life-threatening risk to the client.

The severe thrombocytopenia (platelets

42,000/\text{mm}^3

) while on a high-alert anticoagulant poses a massive risk for internal bleeding.

Nurses must prioritize interventions that prevent imminent harm and rapidly mitigate severe risks.

Anahtar Kavram

Prioritization and Risk Reduction in Laboratory Interpretation

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru