Level 2 Clotting

A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vein thrombosis (DVT)?

Unilateral leg edema

A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize 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 teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

"Use of elastic stockings." Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K.

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 receives a call from a parent of a child who has von Willebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parent?

"Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." The nurse should instruct the parent to have the child sit up with her head tilted forward to reduce the risk of aspiration. The parent should apply pressure with the thumb and forefinger to the child's nose for 10 min and then check for further bleeding.

A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching?

"I have started taking ginger root to treat my joint stiffness." Ginger root can interfere with the blood clotting effect of warfarin and place the client at risk for bleeding. This statement indicates the client needs further teaching.

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 international normalized ratio (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 caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy. The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)

Assess leg for redness. Apply elastic compression stockings. Perform passive range of motion exercises.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit 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 caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

Color Temperature Sensation Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should check the color of the client's affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the extremity as an indication of peripheral neurovascular dysfunction and should notify the provider.

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

Document restraint checks and client status every 2 hr. Educate the clients family about restraint use. Implement passive range-of-motion exercises.

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

Dull, aching calf pain Dull, aching calf pain is a sign of deep-vein thrombosis. Other manifestations are edema, warmth, and redness in the calf.

A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Encourage increased fluid intake. Increased fluid intake will prevent dehydration, which can contribute to the development of deep vein thrombophlebitis.

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 VT prophylaxis following orthopedic surgery.

A nurse is assessing a client who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT?

Groin tenderness Calf pain, groin pain, and unilateral leg swelling are manifestations of DVT.

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

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Hip arthroplasty Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.

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 caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasound. Venous duplex ultrasonography is a noninvasive diagnostic test that assesses the flow of blood and is used to detect distal deep vein thrombosis (DVT).

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

Oral contraceptive use, Immobility - Thromboembolic events are an adverse effect of oral contraceptives - immobility leads to stasis of blood, this increasing the risk for clot formation Other RFs: obesity, trauma

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

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? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Third box from the top 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 on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Vitamin K Vitamin K reverses the effects of warfarin.

A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this 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 caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

Hematocrit (Hct) Epoetin alfa is an antianemic medication that is indicated in the treatment of clients who have anemia due to reduced production of endogenous erythropoietin, which may occur in clients who have end-stage renal disease or myelosuppression from chemotherapy. The therapeutic effect of epoetin alfa is enhanced red blood cell production, which is reflected in an increased BC, Hgb, and Hct.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?

Keep the client's affected leg elevated while in bed. The nurse should keep the client's leg elevated when he is in bed to decrease edema.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Recombinant The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.)

Saw palmetto Glucosamine Gingko biloba Saw palmetto is correct. Saw palmetto is used to relieve symptoms associated with benign prostatic hypertrophy and has an antiplatelet effect. It should not be taken with warfarin. Flaxseed oil is incorrect. It is a source of Omega-3 fatty acids used to promote cardiovascular health. No interactions occur with warfarin. Glucosamine is correct. Glucosamine is used to prevent osteoarthritis and may increase the risk of bleeding. It should not be taken with warfarin. Black cohosh is incorrect. Black cohosh is used for sleep disturbances and depression. No interactions occur when taking warfarin. Gingko biloba is correct. Gingko biloba is used to increase pain-free walking in clients with PVD and may suppress coagulation. It should not be taken with warfarin.

A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?

The client uses garlic to lower cholesterol levels. The nurse should recognize that garlic can potentiate the action of the warfarin.

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

The nurse should not expel the air bubble in the prefilled syringe.

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 teaching a client who is taking atorvastatin daily. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid drinking grapefruit juice." Grapefruits and grapefruit juice can reduce metabolism of atorvastatin, which increases the risk for toxicity.

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching?

"I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following 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 hours 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 deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks 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 IN are within therapeutic range, the heparin can be discontinued.

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

48/min The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage. When a nurse believes there is an error in a prescription, the nurse must question the provider.

A nurse is planning care for a client who has deep-vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to walk. The client should avoid sitting or standing for long periods of time. After the client begins anticoagulant therapy, the nurse should encourage the client to walk.

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

Flexing her knees and feet frequently Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema Increasing edema is a sign of impaired circulation. It is important for client who has a limb fracture to keep the limb elevated to reduce edema.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the clients heel to the popliteal space. If the stocking is too short, if could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.

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/mm?.

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 event of an overdose?

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

A nurse is caring for a client who has thrombophlebitis and is receiving a 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.

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