The nurse is administering the 0900 dose of heparin (an anticoagulant) 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range (excessively elevated). The nurse observes bruising on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. Which actions would the nurse take? Select all that apply.

Question

Quizplus · Accepted Answer

The nurse should notify the prescriber due to the excessively elevated PTT and clotting times, indicating a high risk of bleeding. The medication should be held to prevent further risk of bleeding. It is important to chart the reason the medication was not given for legal and clinical communication purposes. Recording the abnormal findings in the patient's health record is also crucial for ongoing patient care and monitoring. Giving the heparin as ordered (B) would be inappropriate given the current lab values and observed bruising.

The Nurse Is Administering the 0900 Dose of Heparin (An