Heparins
Heparins ( 5 Questions)
A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.
This is correct because heparin is an anticoagulant that prevents blood clotting by inhibiting the formation of thrombin.
The activated partial thromboplastin time (aPTT) is a test that measures how long it takes for the blood to clot.
The normal range for aPTT is 25 to 35 seconds.
A high aPTT indicates that the blood is taking too long to clot, which increases the risk of bleeding.
Therefore, the heparin infusion should be stopped to prevent further bleeding.
This is correct because protamine sulfate is an antidote for heparin overdose.
It binds to heparin and neutralizes its anticoagulant effect.
Protamine sulfate should be administered as ordered by the health care provider to reverse the heparin overdose and restore normal clotting time.
This is correct because the health care provider should be informed of the abnormal aPTT result and the actions taken by the nurse.
The health care provider may order further tests or adjust the heparin dosage or frequency based on the client’s condition and response to treatment.
This is wrong because PT and INR are tests that measure the effect of warfarin, another anticoagulant, on blood clotting.
They are not affected by heparin and are not relevant for this client.
This is wrong because this is not an appropriate action in this situation.
The nurse should not wait for signs and symptoms of bleeding to occur, but should act immediately to stop the heparin infusion, administer protamine sulfate, and notify the health care provider.
Monitoring for bleeding is a preventive measure that should be done before and during heparin therapy, not after an overdose has occurred.
A. Stop the heparin infusion immediately. This is correct because heparin is an anticoagulant that prevents blood clotting by inhibiting the formation of thrombin.
The activated partial thromboplastin time (aPTT) is a test that measures how long it takes for the blood to clot.
The normal range for aPTT is 25 to 35 seconds.
A high aPTT indicates that the blood is taking too long to clot, which increases the risk of bleeding.
Therefore, the heparin infusion should be stopped to prevent further bleeding.
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B. Administer protamine sulfate as ordered. This is correct because protamine sulfate is an antidote for heparin overdose.
It binds to heparin and neutralizes its anticoagulant effect.
Protamine sulfate should be administered as ordered by the health care provider to reverse the heparin overdose and restore normal clotting time.
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C. Notify the health care provider of the result. This is correct because the health care provider should be informed of the abnormal aPTT result and the actions taken by the nurse.
The health care provider may order further tests or adjust the heparin dosage or frequency based on the client’s condition and response to treatment.
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D. Draw a prothrombin time (PT) and international normalized ratio (INR) level. This is wrong because PT and INR are tests that measure the effect of warfarin, another anticoagulant, on blood clotting.
They are not affected by heparin and are not relevant for this client.
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E. Monitor the client for signs and symptoms of bleeding. This is wrong because this is not an appropriate action in this situation.
The nurse should not wait for signs and symptoms of bleeding to occur, but should act immediately to stop the heparin infusion, administer protamine sulfate, and notify the health care provider.
Monitoring for bleeding is a preventive measure that should be done before and during heparin therapy, not after an overdose has occurred.