Care Manager Certification Practice Exam

Which symptom would warrant immediate nursing intervention in a patient receiving heparin therapy?

1. Elevated heart rate

2. Hematuria

3. Increased appetite

4. Weight gain

The correct answer is: Hematuria

Hematuria, or the presence of blood in urine, is a significant symptom that requires immediate nursing intervention in a patient receiving heparin therapy. Heparin is an anticoagulant, which means it helps to prevent blood clots from forming. However, this also increases the risk of bleeding complications. The appearance of blood in urine is an indication that there may be bleeding occurring within the urinary tract, which can lead to serious consequences, such as significant blood loss or the development of further complications. Timely intervention is critical in this situation to assess the cause of the hematuria, provide appropriate treatment, and ensure the safety of the patient. Immediate nursing action may include notifying a physician, stopping heparin therapy, assessing vital signs, and monitoring urine output, among other necessary nursing assessments and interventions. In contrast, elevated heart rate could be a response to various factors, including pain, anxiety, or medication effects; whereas symptoms like increased appetite and weight gain are not directly related to the risks associated with heparin therapy and do not indicate an immediate health emergency. While monitoring all symptoms is important, hematuria is a clear and immediate red flag that signifies a potential bleeding complication that could escalate if not addressed quickly.