Question

A nurse caring for a patient receiving heparin therapy notes that the patient has a heart rate of 98 beats per minute and a blood pressure of 110/72 mm Hg. The patient's fingertips are purplish in color. A stat CBC shows a platelet count of less than 100,000 mm3. The nurse will:

a. administer oxygen and notify the provider.
b. discontinue the heparin and notify the provider.
c. request an order for protamine sulfate.
d. request an order for vitamin K (phytonadione).

Answer 1

The nurse should discontinue the heparin therapy and notify the healthcare provider due to the patient's poor tissue perfusion, low platelet count, and possible heparin-induced thrombocytopenia (HIT).

Step-by-step explanation:

The patient's heart rate of 98 beats per minute, blood pressure of 110/72 mm Hg, and purplish fingertips indicate poor tissue perfusion and possible compromised blood flow. In addition, the low platelet count suggests a potential bleeding disorder. Based on these findings, the nurse should discontinue the heparin therapy and notify the healthcare provider. Heparin is an anticoagulant that can cause severe bleeding, and the patient's symptoms may indicate heparin-induced thrombocytopenia (HIT), a serious adverse reaction.