Question

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.)

a. Laboratory draw for activated partial thromboplastin time (aPTT)
b. Administer vitamin K
c. Laboratory draw for prothrombin time (PT)/international normalized ratio (INR)
d. Administer protamine sulfate
e. Administer enoxaparin (Lovenox)

Answer 1

The nurse should anticipate orders to administer protamine sulfate and perform a laboratory draw for aPTT when managing excessive bleeding due to unfractionated heparin. Administering vitamin K or enoxaparin would not be appropriate in this scenario.

Step-by-step explanation:

A nurse caring for a client who is experiencing excessive bleeding from unfractionated heparin would anticipate orders that aim to reverse the effects of heparin and stabilize the patient's coagulation status. It is common in such cases to:

• Administer protamine sulfate, which is a medication that can reverse the effects of heparin.
• Perform a laboratory draw for activated partial thromboplastin time (aPTT) to assess the extent of anticoagulation and guide the dosage of protamine sulfate.

Other orders might be expected, but they would not include administering vitamin K or enoxaparin, as these are not relevant to heparin reversal.