Question

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. which of the following actions should the nurse take if the client's aPTT is 96 seconds?

A. Administer protamine sulfate
B. Increase the heparin infusion rate
C. Administer vitamin K
D. Withhold the next dose of heparin

Answer 1

The nurse should withhold the next dose of heparin due to the elevated aPTT and signs of over-anticoagulation (hematuria), and consult the healthcare provider for further management. The correct answer D, in this case, is to withhold the next dose of heparin.

Step-by-step explanation:

The nurse should take appropriate action according to the patient's activated partial thromboplastin time (aPTT). An aPTT of 96 seconds is likely significantly higher than the normal therapeutic range, which is typically 1.5 to 2.5 times the normal aPTT value (which varies by laboratory, but is usually around 30-40 seconds). Hematuria while on heparin therapy is an indication of potential over-anticoagulation and bleeding.

The appropriate action in this case would be D. Withhold the next dose of heparin and notify the healthcare provider of the patient's condition. Additional steps may include administering protamine sulfate, which is a reversal agent for heparin, depending on the severity of the bleeding and the aPTT value. However, without specific orders, the first immediate step is to stop the heparin. Vitamin K is not used to reverse the effects of heparin, and increasing heparin would exacerbate the bleeding.