A client receiving an unfractionated heparin infusion develops active bleeding and hypotension. The aPTT is markedly elevated. Which action should the nurse take?
1Continue heparin and give vitamin K because it directly neutralizes circulating unfractionated heparin.
2Stop heparin and administer protamine as a rapid IV bolus based on all heparin given in the past day.
3Reduce the heparin rate by half and wait for the next scheduled aPTT before reporting the bleeding.
4Stop heparin, activate urgent care, and give prescribed protamine slowly based on recent heparin exposure.✓ Correct answer
Explanation
Active bleeding with hypotension during an unfractionated heparin infusion is an emergency. Stop heparin, support the client, notify the urgent response team and prescriber, and administer prescribed protamine slowly. The dose is based on the amount of heparin still active, so recent exposure and elapsed time matter. Rapid administration can cause severe hypotension and other reactions.
Clinical reasoning Protamine binds and neutralizes unfractionated heparin, but both excessive dosing and rapid intravenous administration can cause harm. Heparin activity falls with time, so a full-day total is not the dosing basis.
Decision rule Stop the source, stabilize the client, calculate reversal from recent heparin exposure and elapsed time, then administer protamine slowly with continuous monitoring and resuscitation capability.