Archer NCLEX Prioritization: Practice Test, Study Guide, and Questions

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What is a critical sign of heparin-induced thrombocytopenia that requires immediate nursing intervention?

A sudden increase in blood glucose levels.

A 50% decrease in platelet count.

A 50% decrease in platelet count is a critical sign of heparin-induced thrombocytopenia (HIT), which can lead to serious complications if not addressed promptly. HIT is characterized by a significant drop in platelet counts following heparin administration and can result in an increased risk of thrombotic events, which can be life-threatening.

Recognizing a marked decrease in platelet count is essential for nursing intervention because it indicates the potential development of HIT, necessitating immediate actions such as discontinuing heparin, monitoring the patient's condition closely, and possibly initiating alternative anticoagulation therapy. Vigilance in monitoring platelet levels and early intervention can drastically alter the outcome for the patient.

The other options presented may indicate various issues, but they are not directly correlated with the immediate and serious implications of heparin-induced thrombocytopenia. While changes in blood glucose levels, visible protein in the urine, and new onset of hypertension can be clinical concerns, none have the same level of urgency or critical association with the need to respond to potential HIT as a 50% drop in platelets does.

Visible protein in the urine.

New onset of hypertension.

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