Clotting ATI; Level 4

A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching?

"Clients who are pregnant should not take warfarin." Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and places the fetus at risk for bleeding.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation. Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen." DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Check the activated partial thromboplastin time (aPTT) every 4 hr. Heparin is an anticoagulant. The activated partial thromboplastin time (aPTT) should be monitored every 4 hr and the infusion rate should be adjusted accordingly until the effective dose has been determined.

A nurse is assessing a client who is receiving a unit of PRBC (Packed Red Blood Cells). Which of the following findings is a manifestation of acute hemolytic reaction?

Client report of low back pain Manifestations of an acute hemolytic reaction include apprehension, tachypnea, hypotension, chest pain, and lower back pain.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing a acute episode of disseminated intravascular coagulation. Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged. These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

The nurse starts the transfusion of another unit of blood product. When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Urticaria For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as diphenhydramine prior to the transfusion might prevent future reactions. Allergic reactions typically include urticaria (hives).

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura. When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for

bleeding. Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding. In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client.

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

"You might have to stop taking this medication 5 days before any planned surgeries." Clopidogrel inhibits platelet aggregation and can cause bleeding. The client should report taking this medication to providers to determine whether to discontinue the medication prior to elective procedures to reduce the risk for bleeding.

A nurse is preparing to initiate a transfusion of PRBCs (packed red blood cells) for a client who has anemia. Which of the following action should the plan to nurse take?

Check the client's vital signs every hour during the transfusion. The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction.

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate.

Bleeding The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10g/dL and the hematorcrit is 30%. The nurse recognizes that the client is at risk for which of the following?

Cellular hypoxia The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? SATA

Check vital signs before transfusion is correct. The nurse should check the client's vital signs immediately before starting the transfusion to create a baseline in order to assess a change in the vital signs during the transfusion. Insert an IV with a 19-gauge needle is correct. The nurse should insert a large bore IV to transfuse the blood easily. Check the expiration date of the blood product with a second nurse is correct. The expiration date, the client's name, the hospital number, and the blood compatibility are checked with two nurses to reduce the risk for a transfusion reaction.

is an adverse effect of a platelet transfusion.

Fever

A nurse is caring for a client who has thrombophlebitis and is receiving continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Protamine sulfate Protamine sulfate reverses the effects of heparin by binding with heparin to form a heparin-protamine complex that has no anticoagulant properties.

is a manifestation of a hemolytic transfusion reaction.

Tachycardia

A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the follow statements by the client indicates an understanding of the teaching?

"I'll use my electric razor for shaving." Because this medication prolongs clotting times, the client should avoid situations that put him at high risk for bleeding, such as shaving with a straight razor or a razor blade.

A nurse is teaching a client who has a new prescription for colesevelam to lower his low-density lipoprotein level. Which of the following instructions should the nurse include?

"Take this medication 4 hr after other medications." The client should take this medication 4 hours after other medications to increase absorption of the medication.

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

"Heparin does not dissolve clots. It stops new clots from forming." This statement accurately answers the client's question.

A nurse is caring for a client who had an anaphylactic reaction after a blood transfusion. The nurse reviews the literature to further understand antibody-mediated immunity. Which of the following information should the nurse confirm about AMI?

AMI is mediated by antibodies produced by B-lymphocytes. AMI is mediated by antibodies produced by B-lymphocytes in response to an invading allergen or antigen.

is a manifestation of a nonhemolytic transfusion reaction.

Anxiety

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on left lower forearm. After observing standard precaution, which of the following actions should the nurse perform first?

Apply direct pressure over the wound. The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take is to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding.

A nurse is preparing to administer a transfusion of RBC to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? SATA

Dyspnea is correct. Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention is correct. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is correct. Confusion is a clinical manifestation of fluid volume overload.

A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for the client?

Enoxaparin The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery.

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis?

Enoxaparin subcutaneous Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for DVT prophylaxis following orthopedic surgery.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anti-coagulation pathways.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience. Other findings: Hypotension, Tachycardia, Constipation.

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider?

Fibrinogen 85 mg/dL This fibrinogen level is below the expected reference range and should be reported to the provider. A decreased fibrinogen level can result from its depletion during the blood clotting process.

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic reaction?

Generalized urticaria. The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm.

A nurse is caring for a client who is receiving a unit of PRBCs. 15 minutes followed the start of the transfusion, the nurse note that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

Hemolytic A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse.

A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?

Inject the medication into the abdomen above the level of the iliac crest. The nurse should inject the medication into the abdomen above the level of the iliac crest, at least 2 inches from the umbilicus.

A nurse is planning a care for a client who has leukemia and a platelet count of 130,000. Which of the following interventions should the nurse include in the plan of care?

Limit IM injections. The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward.

A nurse is reviewing the laboratory findings for a client who has idiopathic thromboycytopenic purpura. Which of the following findings should the nurse expect to be decreased?

Platelets The nurse should recognize that ITP results from the destruction of platelets by antibodies; therefore, the nurse should expect a platelet level below the expected reference range.

A nurse is caring for a female client who reports an increase in bruising. The nurse should expect which of the following laboratory values?

Platelets 110,000 mm3 This platelet level is below the expected reference range of 150,000 to 400,000 mm3. Bruising is a manifestation of thrombocytopenia, or low platelet count.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?

Report of low-back pain Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing.

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

Spontaneous bleeding The nurse should consider the risk of spontaneous bleeding that can occur in clients who have low platelets. Low platelet levels cause clotting time to increase.

A nurse is caring for a client for has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

The client experiences sudden weakness of one arm and leg. Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?

The first 15 min The nurse should remain in the room during the first 15 min of the infusion, which is the most critical time period for monitoring a client for a transfusion reaction. Severe reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

Use an electric razor while on this medication. Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measures, such as using an electric razor, to decrease the risk for injury and bleeding.

A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognized that which of the following medications is incompatible with warfarin?

Vitamin K These two medications are not compatible. Vitamin K antagonizes the action of warfarin and is the antidote for warfarin toxicity.

A nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. Which of the following explanations should the nurse provide about the INR test?

"The INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times." The INR is a standardized test, which means that the result will be the same, no matter which laboratory performs it.

A nurse is planning care for a client who has throbocytopenia. Which of the following interventions should the nurse include in the plan?

Apply pressure to needlestick sites for 10 min. A client who has thrombocytopenia has a decreased number of platelets. The nurse should apply pressure to needlestick sites for a minimum of 10 min because of the client's decreased clotting ability.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following indicates the client is experiencing a complication?

Difficulty breathing Brisk capillary refill is incorrect. Brisk capillary refill does not indicate a child is experiencing a complication of a blood transfusion.Difficulty breathing is correct. Difficulty breathing is a manifestation of an air embolism, which is a complication that can occur during blood transfusion.Temperature of 36.8° C (98.3° F) is incorrect. A temperature of 36.8° C (98.3° F) does not indicate a child is experiencing a complication of a blood transfusion.Platelet count 170,000 mm³ is incorrect. A platelet count of 170,000 mm³ is within the expected reference range, and does not indicate a client is experiencing a complication of a blood transfusion.

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend?

Raisins Foods high in iron are recommended to improve a low hemoglobin level. Raisins are a high source of iron.

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? SATA

Lubricate lips with water-soluble ointment is correct. The nurse should instruct the client to lubricate his lips with water-soluble ointment to void cracking, which can result in spontaneous bleeding from the site. Brush teeth with a soft toothbrush is correct. The nurse should instruct the client to brush his teeth with a soft toothbrush to avoid spontaneous bleeding of the gums. Blow nose gently is correct. The nurse should instruct the client to limit blowing the nose, and if needed, to blow the nose gently to minimize spontaneous bleeding from the nares The nurse should instruct the client to shave with an electric razor not a straight edge razor to prevent spontaneous bleeding from nicked skin.

A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

Platelets 74,000/mm3 Heparin-induced thrombocytopenia is a disorder characterized by low platelet counts. It is an adverse effect of heparin that causes the activation of platelets, resulting in widespread clot formation and depletion of platelets. The expected reference range for platelets is 150,000-400,000/mm3.

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory value should the nurse monitor for the therapeutic effect of warfarin?

Prothrombin time (PT) This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation.

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions in nurse's priority?

Stopping the transfusion The greatest risk to this client is injury from a transfusion reaction, which is indicated by chills and back pain. Therefore, the priority intervention is to stop the infusion.

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex?

The nurse should identify the P wave as the initial wave of the sinus rhythm. The P wave is an electrical representation of atrial depolarization.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

The posterior tibial pulse is located on the inner ankle, one-third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is caring for a client who is in warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following meditations should the nurse prepare to administer?

Vitamin K Vitamin K reverses the effects of warfarin.

A nurse is preparing to administer a unit of RBCs. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

identification wristband This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority.

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the even of an overdose?

Protamine Protamine reverses the effects of heparin and is used in the event of an overdose.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mmHg. Which of the following actions should the nurse take first?

Stop the infusion of blood. This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client ask the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?

Chills Severe chills is an adverse effect of a platelet transfusion. The client might require premedication of diphenhydramine and acetaminophen to reduce this reaction.

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

Ecchymosis A client who as ITP has a decreased number of circulating platelets, which are important for blood clotting. One of the first manifestations seen in clients who have an exacerbation of ITP is the development of bruises (ecchymoses) and petechiae. The greatest risk to this client is bleeding. Therefore, the nurse's priority is to monitor for occult bleeding and the development of ecchymosis.

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of PRBCs ) packed red blood cells). The client becomes apprehensive and tachycardia, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause fever, chills, hypotension, possible chest pain, and hemoglobinuria.

A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?

Stop the infusion. The greatest risk to this client is injury from a transfusion reaction, which can be more harmful if the client receives more of the blood product. Therefore, the first action the nurse should take is to stop the infusion.

A nurse is assessing a client who is receiving a unit of PRBCs. The client appears flushed and reports low back pain. Which of the following actions is the nurse's priority?

Stop the transfusion. The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When a hemolytic reaction is suspected, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis.

A nurse is caring for a client who is receiving a transfusion of PRBC (packed red blood cells) and suspects that a client is experiencing a hemolytic reaction. Which of the following interventions is the priority?

Stop the transfusion. The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When suspecting a hemolytic reaction, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis.