Difficulty: Medium
Average Score: 85%
Simulated
The nurse is reviewing laboratory results for a client with sepsis. The results are as follows: WBC: 11,000/mm┬│ (normal range: 5,000-10,000 mm┬│), PaO2: 90 mm Hg (normal range: 80-100 mm Hg), aPTT: 50 seconds (normal range: 30-40 seconds), Platelet count: 98,000/mm┬│ (normal range: 150,000-400,000 mm┬│). What is the nurse's priority action?
Correct answer
D
Rationale
The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.