A nurse assessing a client on a heparin drip notes bloody drainage in the nasogastric tube and indwelling urinary catheter.A stat partial thromboplastin time (PTT)is drawn according to heparin protocol.The result is 224 seconds.Which action by the nurse is the most appropriate?

Question

Quizplus · Accepted Answer

A PTT of 224 seconds indicates that the client is at high risk for bleeding due to excessive anticoagulation with heparin. The presence of bloody drainage in nasogastric tube and indwelling urinary catheter further supports this. The most appropriate action by the nurse is to notify the healthcare provider immediately and prepare to administer protamine sulfate, the antidote for heparin. Option B is incorrect because increasing the IV rate and administering aminocaproic acid is contraindicated in a client who is already at high risk for bleeding. Option C is incorrect because obtaining a unit of clotting factors is not the appropriate intervention for heparin overdose. Option D is incorrect as vitamin K is the antidote for warfarin, not heparin.

A Nurse Assessing a Client on a Heparin Drip Notes