Davis Advantage left and right heart failure
While caring for the patient in the hospital with a diagnosis of deep vein thrombosis (DVT), the nurse recognizes that the most serious potential complication from a DVT is what?
A. Development of a pulmonary embolism
You contact the healthcare provider with the nursing assessment findings. What is the primary lab test that you would expect the healthcare provider to order for Bob's assessment findings?
D-dimer You would expect the healthcare provider to order a D-dimer test. A serum D-dimer measures the byproducts of a clot breaking down. A negative D-dimer lab test excludes a DVT without the need for compression ultrasonography. An elevated D-dimer can result from other medical conditions than a DVT, so more testing would be required to confirm diagnosis. Next
The nurse is explaining to the nursing student the concept of Virchow's triad, the three mechanisms that can create a venous thrombosis. The nurse explains that which of the following is not a mechanism included in Virchow's triad?
Decreased # of platelets
You are completing your shift assessment on Bob. He states there is a soreness and moderate pain in the right calf under the sequential compression device (SCD). You gently palpate the right calf and note hardening along the blood vessel and warmer skin than that of the left calf. What action should the nurse take next?
perform visual assessment
What should you do with the SCD after the assessment is complete?
Do not replace the SCD because the compression could potentially dislodge a blood clot
Which is a cause for diastolic dysfunction for a patient diagnosed with heart failure?
left ventricle hypertrophy
The client calls the nursing station, saying he is short of breath and feels very anxious. What is your priority action? Obtain vital signs, including oxygen saturation. Medicate the client for anxiety. Call the healthcare provider. Check peripheral pulses bilaterally in the client's lower extremities.
Obtain vital signs, including oxygen saturation The client is demonstrating symptoms of a pulmonary embolism, a complication of DVT. Of the interventions listed, you should first obtain a set of vital signs, including oxygen saturation. Checking the peripheral pulses is an important assessment step but is not related to the client's present concern. Medicating the client for anxiety is not the current priority. The healthcare provider will need to be contacted but not until the client is reassessed and vital signs are obtained.
Which client should be classified, according to the American Heart Association and American College of Cardiology, as stage C?
client w certain symptoms of HF
The D-dimer shows a high probability for a thrombus. What diagnostic test should you anticipate will be ordered next?
compression ultrasonography If the D-dimer indicates a probable thrombus, the next step is to perform compression ultrasonography. Rarely is venography needed or utilized. Next
The nurse is caring for an older adult who is on prolonged bed rest and suspected of having a deep vein thrombosis. What is the priority action?
contact provider
Which symptoms should the nurse anticipate when providing care to a client who is diagnosed with left-sided heart failure?
cyanosis, s3 and s4 sounds, weak peripheral pulses
Which clinical manifestations should the nurse anticipate when providing care to a client who is diagnosed with right-sided heart failure?
dependent edema & JVD
Which medications should the nurse anticipate for a client diagnosed with heart failure who requires positive inotropic therapy? Select all that apply.
digoxin
You remove Bob's sequential compression device (SCD) from the right leg to continue the assessment. Which finding is most concerning?
discoloration and redness of right calf
Which drug classification should the nurse anticipate for a client diagnosed with heart failure to increase urine output?
diuretic
Which clinical manifestations should the nurse anticipate when providing care to a client who is diagnosed with left sided heart failure?
dyspnea, fatigue, and crackles noted on lung auscaultation
Which is a cause for high-output failure for a patient diagnosed with heart failure?
elevated demands on the heart
Which medication should the nurse anticipate for a client diagnosed with heart failure with pulmonary edema?
furosemide
The nurse is admitting the client to the nursing unit at the hospital. The nurse is assessing the risk for deep vein thrombosis. Which factors are concerning?
stasis of blood flow damage to blood vessel walls The Virchow's triad includes a decreased flow of blood, endothelial injury, and hypercoagulability. This client has blood stasis from immobility (decreased blood flow) and blood vessel injury from the fracture (endothelial injury). No history indicates that he is at risk for hypercoagulability (increased tendency for blood clotting).
It is determined that the client has a right calf deep vein thrombosis. Which medications may be initiated?
unfractured heparin low molecular weight heparin Warfarin Medication for the acute treatment of a DVT typically includes heparin (unfractionated or low molecular weight). Warfarin is also initiated since the client will be discharge with this and need proper anticoagulation prior to discharge. Tissue plasminogen activator and aspirin are not routinely used for a known DVT.
