A client who underwent a total hip arthroplasty 5 days ago has been receiving enoxaparin for deep vein thrombosis (DVT) prophylaxis. The nurse notes localized skin necrosis at the injection site, and the client's laboratory results reveal a platelet count drop from 220000/mm3 to 20000/mm3 . Which action should the nurse take immediately?

1. A

   Maintain standard protocols, document the findings, and continue to monitor the client.

2. B

   Prepare for an emergency platelet transfusion to correct the thrombocytopenia.

3. C

   Administer the next scheduled dose of enoxaparin and request a repeat complete blood count (CBC).

4. D

   Discontinue all heparin-containing products and immediately notify the surgeon.

Appeared in: NORCET 10 Mains

Explanation

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• The client's signs—a platelet count drop of over 50% and skin necrosis at the injection site 5 days after starting enoxaparin—are classic indicators of Heparin-Induced Thrombocytopenia (HIT).
• HIT is a medical emergency that causes a prothrombotic state despite the low platelet count.
• The absolute first priority in managing suspected HIT is to immediately withdraw the causative agent, which includes all forms of heparin (including enoxaparin).
• Notifying the surgeon is the essential next step to ensure a new, non-heparin anticoagulant is ordered to manage the client's ongoing DVT risk.

Why Other Options Were Wrong

• Option A: This response is passive and dangerous. HIT is a life-threatening condition that requires immediate intervention, not just monitoring. Continuing to monitor without stopping the heparin would lead to worsening thrombosis.
• Option B: Platelet transfusion is contraindicated in HIT unless there is active, life-threatening hemorrhage. The transfused platelets can be activated by the HIT antibodies, which paradoxically increases the risk of thrombosis.
• Option C: Administering more enoxaparin would worsen the immune reaction, accelerate platelet destruction, and significantly increase the risk of a catastrophic thrombotic event like a pulmonary embolism or stroke.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Management of Heparin-Induced Thrombocytopenia (HIT) helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Nurses play a critical role in the early detection of HIT by diligently monitoring platelet counts for any patient receiving heparin products. A drop of 50% or more should always be treated as a red flag.
• This scenario highlights a crucial patient safety principle: recognizing and acting immediately on signs of a severe adverse drug reaction. The nurse's prompt action can prevent death or disability.
• What if? If the client's platelet count had dropped from 220,000/mm³ to 180,000/mm³ (an 18% drop) without skin necrosis, the immediate action would be different. The nurse should still notify the provider and recommend more frequent CBC monitoring, but immediate discontinuation might not be the first step, as this smaller drop is less specific for HIT.

How to Approach the Question

• First, analyze the clinical scenario for key data. Note the medication (enoxaparin, a heparin product), the timeline (5 days), and the two critical findings: skin necrosis and a massive platelet drop (>90%).
• Connect these findings to a known complication. A significant platelet drop after starting heparin is the hallmark of Heparin-Induced Thrombocytopenia (HIT).
• Recall the pathophysiology of HIT: it's an immune reaction that causes clotting, making it a medical emergency.
• Evaluate the options based on the priority intervention for this emergency. The number one rule for any severe adverse drug reaction is to stop the offending agent.
• Eliminate options that are passive (monitoring), contraindicated (platelet transfusion), or would cause further harm (administering more of the drug).
• Select the option that reflects the immediate, life-saving action: stop all heparin and notify the provider.

Concept Tested & Keywords

• Concept Tested: Management of Heparin-Induced Thrombocytopenia (HIT)
• Stem keywords: total hip arthroplasty, enoxaparin, DVT prophylaxis, skin necrosis, platelet count drop
• Lead-in keywords: action, immediately
• Clinical cues: The platelet drop from 220,000/mm³ to 20,000/mm³ is a greater than 90% reduction, which is a critical indicator of HIT.
• Clinical cues: Skin necrosis at the injection site is a specific sign of localized thrombosis associated with HIT.

Question ID

QMnqrweZyaywT_MYONGhrL

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Reference Book

E6 Medicine Harrison 22e Part 1 p. 989-991