DVT PE review
A 45-year-old male client with a confirmed DVT is being discharged from the ED. Which of the following client statements indicates that the client has received proper nursing instruction and understands how to manage his condition?
"I need to do my leg exercises five times or more every hour."
Heparin therapy is usually considered therapeutic when the patient's activated partial thromboplastin time (aPTT) is how many times normal?
2 to 2.5
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
Check urine for bright blood and a dark smoky color. Walk daily as a good exercise. Perform foot/leg exercises and walk around the airplane cabin on long flights. Prevent DVT because of risk of pulmonary emboli. Avoid surface bumps because the skin is prone to injury.
A deep vein thrombosis (DVT) results in vascular vasodilation, local tissue congestion, and increased capillary permeabilty. The nurse would expect to see which of the following body responses in a client with a DVT?
Erythema and pain
You are caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
Examine the legs for color, capillary refill time, and tissue integrity.
The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?
Inspect the left lower leg for areas of redness.
Which of the following are risk factors related to venous stasis for DVT and pulmonary embolism?
Obesity
Which of these measures would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?
Placing graduated compression stockings on the client.
A client has had oral anticoagulation ordered. What should you monitor for when your client is taking oral anticoagulation?
Prothrombin time (PT) or international normalized ratio (INR)
A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?
Pulmonary embolism
A nurse is administering enoxaparin, (anticoagulant) to a patient with DVT, via the subcutaneous route. Which of the following is a recommended guideline when administering a subcutaneous injection?
Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.
When the nurse is obtaining a health history from an older adult, which information in the history is a risk factor associated with deep vein thrombosis (DVT)?
The client recently had abdominal surgery.
A patient is receiving enoxaparin (Lovenox) and warfarin (Coumadin) therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin (Lovenox) can be discontinued?
The patient's international normalized ratio (INR) is 2.5.
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first:
assess the oxygen saturation
Following a total joint replacement, which complication has the greatest likelihood of occurring?
deep vein thrombosis (DVT)
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4° F (38° C). The nurse should assess the client further for signs of:
deep vein thrombosis (DVT) in the left leg.
Which client is at risk for pulmonary embolism? A client with:
deep vein thrombosis (DVT).
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
forcing blood into the deep venous system.
In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should:
use pneumatic compression stockings.
