PrepU: Clotting
A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure?
Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take?
Perform a neurologic assessment with vital signs
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?
Vitamin K
Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy?
aspirin
A client with a history of mitral stenosis is admitted to the intensive care unit (ICU) with the abrupt onset of atrial fibrillation. The client's heart rate ranges from 120 to 140 bpm. The nurse recognizes that interventions are implemented to prevent the development of
embolic stroke.
A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding?
"What color is your urine?"
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe stools for blood. Observing the stool for blood will help detect blood from GI loss.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing dressings or applying pressure if bleeding is frank
A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis?
Tamoxifen - Deep vein thrombosis, pulmonary embolism, and superficial phlebitis are all thromboembolic events that are adverse reactions to tamoxifen.
The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?
international normalized ratio (INR) - INR is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, - Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.