The nurse is caring for a patient receiving a heparin infusion for the management of a pulmonary embolus (PE). The nurse observes bright red urine in the patient's catheter bag. What should be done first?

Notify the physician

Explanation

•Hematuria is a sign of anticoagulation and heparin overdose. The physician should be notified to determine the plan of action.

•Protamine is the antidote for heparin overdose. Since the heparin infusion is used to treat a pulmonary embolism, protamine should not be given unless confirmed by the physician.

•A PTT should be checked, but only after the immediate threat is dealt with.

Visit our website for other NCLEX topics now!