Module 4 Coagulation
The nurse is reviewing the history and assessment data for a client who had a total hip replacement 24 hours ago. Which complication would the nurse suspect? Fat embolism Urinary retention Hypovolemic shock Pulmonary embolism
Fat embolism Rationale: The client most likely is experiencing fat embolism syndrome (FES). The average time of onset of FES is 18 to 24 hours after injury to long bones or a crushing injury. Fat globules and tissue thromboplastin exit from bone marrow and local tissue as a result of injury. Fat molecules enter venous circulation, move to lungs, and embolize small capillaries. Petechial rash on the neck, chest, conjunctivae, or axillae is a classic sign of FES (it occurs in 50%-60% of clients with FES). Increased temperature, pulse rate, and respirations are associated with FES; 75% of clients with FES exhibit neurological signs, such as altered mental state, restlessness, agitation, lethargy, confusion, or coma. The client is not experiencing urinary retention because output indicates adequate hourly output of at least 50 mL/h. The client is not experiencing hypovolemic shock. Although the client may experience tachypnea, tachycardia, and an increased temperature with hypovolemic shock, the blood pressure will decrease, and the urine output will decrease to less than 30 mL/h. The client is not experiencing a pulmonary embolism; this is more likely to occur 4 to 10 days after trauma. Although tachypnea, tachycardia, an increased temperature, restlessness, and agitation are common with pulmonary embolism, the client is not exhibiting sudden chest pain, dyspnea, cough, hemoptysis, or areas of dullness or crackles when auscultating breath sounds.
The nurse suspects a thrombus after assessing a client who has pain in her right calf 2 days after a cesarean birth. Which is the nurse's immediate action? Confine client to bed. Apply warm soaks Perform leg exercises. Massage the affected area.
Confine client to bed. Rationale: When a thrombus is suspected but before a definitive diagnosis is made, the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.
The nurse suspects a client has a pulmonary embolus based on which characteristic of the client's sputum? Pink Clear Green Yellow
Pink Rationale: With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.
Which rationale would the nurse include to address the client's concern about why both warfarin and intravenous (IV) heparin are needed at the same time for a partial occlusion of the left common carotid artery? This permits the administration of smaller doses of each medication. Giving both medications allows clot dissolution while preventing new clot formation. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Administration of heparin with warfarin provides immediate and maximum protection against clot formation.
Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Rationale: Warfarin is administered orally for 2 to 3 days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. Because each medication affects a different part of the coagulation mechanism, dosages must be adjusted separately. These medications do not dissolve clots already present. That this approach immediately provides maximum protection against clot formation is not the reason for the administration of both medications; warfarin will not exert an immediate therapeutic effect.
Which task can be delegated safely by the registered nurse (RN) to unlicensed assistive personnel (UAP) for a client with thrombocytopenia? Shaving the client Positioning the client Maintaining oral hygiene Giving intravenous platelet infusions
Positionaing the client Rationale: Clients with thrombocytopenia are at risk of bleeding with slight bruising. Tasks that do not risk bruising may be delegated to the UAP such as carefully positioning the client. The RN would shave the client and maintain oral hygiene. Intravenous infusions should not be administered by a UAP to any client.
Which client in the pulmonary clinic will the nurse plan to teach about pulmonary function testing? Client who has Chronic Obstructive Lung Disease (COPD) Client who is being evaluated for lung histoplasmosis Client who is recovering after pulmonary embolism Client who has had positive tuberculosis skin testing
Client who has Chronic Obstructive Lung Disease (COPD) Rationale: Pulmonary function testing is used to diagnose and determine progression of disease in clients with COPD. Pulmonary function testing is not used to evaluate for clients for histoplasmosis or pulmonary embolism, because pulmonary embolism affects blood vessels rather than airflow and respiratory effort and evaluation of histoplasmosis requires laboratory testing. A client with a positive tuberculosis skin test would be taught about chest x-ray and sputum testing.
Which finding would the nurse expect when assessing the nasal passages of a client with thrombocytopenia? Blood clots Nasal polyps Purulent discharge Pale, swollen turbinates
Blood clots Rationale: Thrombocytopenia increases risk for epistaxis and the nurse may see bleeding or clots. Nasal polyps are not associated with thrombocytopenia. Purulent discharge may occur with foreign bodies in the nose or sinus infection, but would not be expected with thrombocytopenia. Pale and swollen turbinates are caused by allergies and not associated with thrombocytopenia.
The parents of a toddler with newly diagnosed cystic fibrosis ask the nurse what causes the problems related to this disorder. Which alteration would the nurse consider about the primary pathologic process before responding? Hyperactivity of the eccrine (sweat) glands Hypoactivity of the autonomic nervous system Mechanical obstruction of mucus-secreting glands Atrophic changes in the mucosal lining of the intestines
Mechanical obstruction of mucus-secreting glands Rationale: Mucous secretions increase in viscosity and precipitate or coagulate to form concentrations in glands and ducts, resulting in obstructions. Decreased amounts of pancreatic enzymes cause impairment in the digestion and absorption of nutrients. The eccrine (sweat) glands are not hyperactive, but there is an increased concentration of sweat electrolytes (e.g., sodium and chloride). The autonomic nervous system does not play a role in the pathologic process of cystic fibrosis. There is no alteration in the mucosal lining of the intestines.
Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? Severe right calf pain Right calf redness and swelling Oxygen saturation 89% Heart rate of 136 beats/minute
Oxygen saturation 89% Rationale: Low oxygen saturation in the setting of venous thrombosis may indicate pulmonary embolism, which will require rapid interventions, such as actions to improve oxygenation. Severe right calf pain is consistent with the client diagnosis of right calf venous thrombosis. Right calf redness and swelling are consistent with a diagnosis of right calf venous thrombosis. The elevated heart rate may be due to pulmonary embolism, and improvement of oxygen saturation would also decrease the heart rate.
The nurse, providing care for a client who had a hysterectomy, is concerned about the client's risk for postoperative thrombosis. The nurse remembers that, after pelvic surgery, the majority of pulmonary emboli begin as deep vein thromboses in which area? Calf Thoracic cavity Pelvis and thighs Extremities and abdomen
Pelvis and thighs Rationale: Most pulmonary emboli after surgery of the pelvic floor originate in the deep veins of the pelvis and thighs because of the extensive vascular network in the region. The calf, thoracic cavity, extremities, and abdomen are not where most pulmonary emboli originate after surgery involving the pelvic floor.
Which possible complication would a nurse monitor for when a client develops a venous thrombosis in the left calf? Embolic stroke Pulmonary embolism Myocardial infarction Ischemia of the left foot
Pulmonary embolism Rationale: Because the venous system returns blood to the right side of the heart and then blood flows to the pulmonary circulation, emboli from the venous thrombosis may cause apulmonary embolism. Embolic stroke occurs with thrombus formation in the left atrium or ventricle. Myocardial infarction occurs when thrombus forms over ruptured coronary artery plaque. Ischemia of the foot would occur with an embolus in the distal arterial system
Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? Coagulability of the blood Velocity of the venous return Effectiveness of internal respiration Oxygen-carrying capacity of the blood.
Velocity of the venous return Rationale: Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. Effectiveness of internal respiration and oxygen-carrying capacity of the blood will not affect the prevention of deep vein thrombosis.
When a client with a suspected pulmonary embolism is scheduled for a spiral computed tomography (CT) scan, which action would the nurse take before the procedure? Check the client's blood glucose levels. Obtain informed consent from the client. Assess if the client is allergic to shellfish. Instruct the client to remove dentures.
Assess if the client is allergic to shellfish. Rationale: Before preparing the client for the test, the nurse would assess if the client is allergic to shellfish because the contrast used in the test is iodine based. Blood glucose level will not affect the spiral CT testing. Informed consent is not needed for spiral CT. Dentures may remain in place for spiral CT.
When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? Chest x-ray Thoracic ultrasound Helical computed tomography (CT) Magnetic resonance imaging (MRI)
Helical computed tomography (CT) Rationale: Helical CT is the gold standard and most commonly used test to detect pulmonary embolism. Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool. Thoracic ultrasound might be used for pleural effusion, but not to diagnose pulmonary embolism. MRI testing is not used for diagnosis of pulmonary embolism.
When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy Inactivity Aerobic exercise Tight clothing
Inactvity Rationale: A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.
Which clinical manifestation indicates a possible pulmonary embolism in a client after a total hip replacement? Select all that apply. One, some, or all responses may be correct. Sudden chest pain Flushing of the face Elevation of temperature Abrupt onset of shortness of breath Hip pain rating increased from 2 to 8
Sudden chest pain Abrupt onset of shortness of breath Rationale: Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip
The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery A 76-year-old who has a history of thrombocytopenia
A 59-year-old who had a knee replacement Rationale: Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for which process? Bile production Blood production Blood clotting Digestion of fats
Blodd clotting Rationale: Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction and nerve impulses; however, it is not directly related to bile and blood production or digestion of fats
Which diagnosis increases the risk for development of a pulmonary embolism? Atrial fibrillation Forearm laceration Migraine headache Respiratory infection
Atrial fibrillation Rationale: Inadequate atrial contraction that occurs during fibrillation leads to the pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headaches. Respiratory infections do not increase pulmonary embolism risk
A client has a peripherally inserted central catheter (PICC) in place. The client notifies the nurse that the catheter got tangled up in bedclothes and came out. Which action would the nurse take to determine the likelihood of a catheter embolus? Inspect the catheter. Obtain an oxygen saturation level. Observe the catheter insertion site. Assess the lung sounds.
Inspect the catheter. Rationale: The nurse should first assess the catheter to see if anything may have broken off. Anything that damages the catheter during insertion, dressing change, or excessive force may cause a catheter embolism, which could be a life-threatening situation. If the catheter is broken, the nurse should perform a quick respiratory assessment and take vital signs. It is important to evaluate the client's respiratory status (oxygen saturation level and lung sounds) and to observe the site. However, the nurse is seeking information about the likelihood of an embolism, and this information does not assist with this process.
Which substance does vitamin K contributes to the formation of? Bilirubin Prothrombin Thromboplastin Cholecystokinin
Prothrombin Rationale: Vitamin K is necessary in the formation of prothrombin to prevent bleeding. It is a fatsoluble vitamin and is not absorbed from the gastrointestinal (GI) tract in the absence of bile. Bilirubin is the bile pigment formed by the breakdown of erythrocytes. Thromboplastin converts prothrombin into thrombin during the process of coagulation. Cholecystokinin is the hormone that stimulates contraction of the gallbladder.
In which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism? Check oxygen saturation using pulse oximetry. Administer oxygen to keep saturation higher than 93%. Place client on cardiac monitor. Obtain blood for coagulation studies. Administer unfractionated heparin.
It is already in order so repeat it Rationale: The initial action for a client with dyspnea and chest pain will be obtain a baseline oxygen saturation and then start oxygen administration. Because dysrhythmias can occur because of hypoxemia secondary to pulmonary embolus, the nurse will start cardiac monitoring. Rapid administration of anticoagulants is needed, but baseline coagulation studies are needed prior to starting anticoagulation.
Which drug action will the nurse include when describing the purpose of heparin in a client who develops thrombophlebitis in the right calf and is prescribed bed rest and initiated on an intravenous (IV) infusion of heparin? It prevents extension of the clot. It reduces the size of the thrombus. ' It dissolves the blood clot in the vein. It facilitates absorption of red blood cells.
It prevents extension of the clot. Rationale: Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells.
Which manifestation would the nurse expect to find upon assessment of a client with a 10-year history of emphysema hospitalized for acute respiratory distress? Chest pain on inspiration Decreased respiratory rate Signs and symptoms of respiratory alkalosis Prolonged expiration with use of accessory muscles
Prolonged expiration with use of accessory muscles Rationale: Accessory muscles are used during respiration because of the increased rigidity of the chest. Sudden pleuritic chest pain is associated with pulmonary embolism, not emphysema. Clients with respiratory muscle fatigue breathe with rapid, shallow respirations. Respiratory acidosis, not alkalosis, is associated with emphysema because of carbon dioxide retention.
On the second day after surgery, a client reports pain in the right calf. Which action would the nurse take first? Apply a warm soak to the leg. Document the symptom. Elevate the leg above the heart. Notify the primary health care provider.
Notify the primary health care provider. Rationale: Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the primary health care provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.
Which integumentary change would a nurse anticipate in a client with a platelet count of 60,000/µL (60 × 10 /L)? Select all that apply. One, some, or all responses may be correct. Cyanosis Petechiae Varicosity Ecchymosis Hematoma
Petechiae Ecchymosis Hematoma Rationale: Normal blood platelet counts range between 150,000 and 400,000/µL (150-400 × 10 /L). A count of less than 100,000/µL (100 × 10 /L) is referred to as thrombocytopenia, which results in prolonged bleeding time. Petechiae, ecchymosis, and the formation of hematoma are the results of bleeding disorders. Cyanosis is caused by cardiorespiratory problems, vasoconstriction, asphyxiation, and deoxygenated blood.
Which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? Select all that apply. One, some, or all responses may be correct. Place a pillow between the client's legs. Require the client to sit in an armless chair. Cross the client's legs at the ankles and knees. Require the client to use an elevated toilet seat. ' Keep the client's hip in a neutral, straight position.
Place a pillow between the client's legs Require the client to use an elevated toilet seat. ' Keep the client's hip in a neutral, straight position. Rationale: A client who has undergone hip replacement needs help while standing; therefore, the nurse should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. Crossing the client's legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. Using a pillow between the legs provides comfort and helps keep the joint abducted. Use of an elevated toilet seat allows for easy movement and prevents hip dislodgement. Keeping the client's hip in a neutral, straight position prevents pain and discomfort and hip dislocation. Test-Taking Tip: Be alert for details about what you ar
What would the nurse include in the plan of care to minimize the potential for a sickling episode in a child with sickle cell anemia? Providing an iron-rich diet Ensuring hemoconcentration Enforcing periods of quiet play Promoting adequate oxygenation
Promoting adequate oxygenation Rationale: Low oxygen tension may precipitate sickling; therefore adequate oxygenation is desirable. Oral intake of iron may contribute to iron overload. Some children with sickle cell anemia receive frequent transfusions to suppress the production of red blood cells containing the sickle hemoglobin. Hemoconcentration results in increased viscosity, which promotes thrombus formation and sickling. Quiet play is desirable during a painful episode, but it is not used routinely to prevent a crisis.
A 25-year-old woman on estrogen therapy has a history of smoking. Which is a potential complication for this individual? Osteoporosis Hypermenorrhea Endometrial cancer Pulmonary embolism
Pulmonary embolism Rationale: Estrogen therapy increases the risk of pulmonary embolism in clients who have a history of smoking because the medication affects blood circulation and hemostasis. Osteoporosis may be caused by reduced bone density observed in postmenopausal woman. Hypermenorrhea (excessive menstrual bleeding) is treated with estrogen therapy. Endometrial cancer is a complication of estrogen therapy seen in postmenopausal woman.
When a client who has thrombophlebitis tells the nurse, "I am worried about getting a clot in my lungs that will kill me, " which action will the nurse take next? Ask what the client already knows about complications of thrombophlebitis. Tell the client that most people with thrombophlebitis do not develop pulmonary emboli. Teach the client that anticoagulant use helps decrease the risk for a pulmonary embolism. Instruct the client to tell the nursing staff about any chest pain of shortness of breath.
Ask what the client already knows about complications of thrombophlebitis. Rationale: The nurse's first action would be to determine the client's current understanding of thrombophlebitis and pulmonary embolism risk. It is true that most people with thrombophlebitis do not develop pulmonary embolism and this may be reassuring to the client, but more assessment of the client is needed first. The client's anxiety may be decreased by knowing that anticoagulant use will help decrease pulmonary embolism risk, but more assessment of the client's knowledge is needed first. The client may be instructed to notify nursing staff about any clinical manifestations of pulmonary embolism, but the nurse will need to assess the client's current knowledge and emotional state first
Which priority action would the nurse instruct a woman who recently under went a hysterectomy to take after she calls the clinic and states that she has tenderness, redness, and swelling in her right calf? Stay in bed for at least 3 days." "Keep the legs elevated while sitting." "Apply a warm compress to the affected calf twice a day." "Go to the emergency department immediately."
"Go to the emergency department immediately." Rationale: The client's description of her problem is indicative of thrombophlebitis; this is a medical emergency because it may precipitate a pulmonary embolism. The client must be assessed by a primary health care provider. Intravenous anticoagulants will probably be necessary. Although bed rest may be prescribed eventually, a delay in pharmacological treatment may jeopardize the client's status. Elevation of the legs may be prescribed eventually after the thrombophlebitis is resolved. Although warm compresses are commonly prescribed, a delay in pharmacological treatment may jeopardize the client's status.
After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? "I will avoid crossing my legs." "Pillows placed under my knees will help avoid clots." "Staying on bed rest as long as possible is best for me." "Three times every day I will massage my lower legs to get blood moving."
"I will avoid crossing my legs." Rationale: Clients should avoid crossing the legs to prevent the constriction of blood flow in the lower leg, which can lead to deep vein thrombosis (DVT). When dislodged, DVT can become a pulmonary embolus. Pillows should not be placed under the knees because this constricts blood flow to and from the lower leg and increases risk for DVT. Activity, rather than staying immobile in bed, helps encourage blood flow. The lower legs should not be massaged because this action could dislodge a DVT that has formed.
The nurse prepares to administer vitamin K to a newborn. Which rationale explains why newborns are deficient in this vitamin? Alterations in blood coagulation interfere with vitamin K production. A newborn's liver does not produce it immediately after birth. Increased bilirubin levels interfere with vitamin K synthesis during the neonatal period. A newborn's intestinal tract does not synthesize it for several days after birth.
A newborn's intestinal tract does not synthesize it for several days after birth. Rationale: Because the infant's intestine is sterile at birth, it lacks the flora to synthesize vitamin K, which activates coagulation factors and prevents hemorrhage in the newborn. The liver does not produce vitamin K; vitamin K catalyzes the synthesis of prothrombin in the liver. Hyperbilirubinemia may develop because of complex factors; however, this does not inhibit vitamin K synthesis. Vitamin K alters blood coagulation, not vice versa.
Which action will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. One, some, or all responses may be correct. Administer oxygen at high flow rates. Notify the Rapid Response Team. Lower the head of the client's bed. Place the client on a cardiac monitor. Anticipate rapid administration of warfarin.
Administer oxygen at high flow rates. Notify the Rapid Response Team. Place the client on a cardiac monitor. Rationale: Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. Cardiac monitoring is needed because the client is at risk for dysrhythmias. The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonary embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin
Which discharge instruction would the nurse give the client to decrease the risk of thromboembolic events after an abdominal hysterectomy? Avoid sitting for long periods of time. Limit fluids to less than 2000 mL per day. Have a blood coagulation test every 2 weeks. Continue with hormone replacement therapy.
Avoid sitting for long periods of time. Rationale: Sitting for long periods leads to pooling of blood in the pelvic area, predisposing the client to thrombus formation. Fluids should be increased to about 2000 mL daily to decrease blood viscosity, which can lead to thrombus formation. Blood coagulation tests are not done routinely because clotting elements are not usually disturbed by a hysterectomy. Hormone replacement therapy is not considered unless the client is premenopausal and an oophorectomy has also been performed. The estrogen component in hormone replacement therapy can increase the risk of clots.
A client is taking an estrogen-progestin oral contraceptive. Which adverse effects from the contraceptive would the nurse teach the client to report to the primary health care provider? Select all that apply. One, some, or all responses may be correct. Dizziness Chest pain Bloating Nausea Calf tenderness Breast tenderness
Dizziness Chest pain Calf tenderness Rationale: Early side effects of oral contraceptives include bloating, nausea, and breast tenderness. Although they may be bothersome enough to lead to discontinuation of the contraceptive, these side effects usually subside in several months. Dizziness is not a common side effect and should be reported to the provider. Contraceptives have been associated with thrombophlebitis; clinical manifestations of thrombophlebitis include calf tenderness and redness and heat over the affected area. If the clot travels, it could present as a pulmonary embolism, so chest pain should be reported as well.
Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct. Floss twice daily to prevent the need for dental work. Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes. Use enemas to prevent straining during bowel movements.
Avoid eating hot food or liquid that can burn the mouth. Use an electric shaver instead of a straight-bladed razor. Apply ice to any areas of trauma like bumps and scrapes. Rationale: The goal of self-care for clients on anticoagulation therapy is to prevent bleeding. Clients should avoid eating hot food or liquid, which can burn the mouth, disrupt the mucous membrane, and encourage bleeding. Clients should use an electric shaver instead of a straight-bladed razor to avoid cuts. Clients should be instructed to apply ice to any areas of trauma, such as bumps and scrapes, to slow blood flow and minimize bleeding. Clients on anticoagulation therapy should not floss because this can cause the gums to bleed; however, they should be encouraged to brush their teeth with a soft tooth brush and make sure their dentist knows they are on anticoagulants. Stool softeners, rather than enemas, should be used to prevent straining because enemas can cause rectal bleeding.
A postpartum client is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client cue is of most concern to the nurse? Dyspnea Pulse rate of 62 beats/min Blood pressure of 136/88 mm Hg Positive Homan sign in the left leg
Dyspnea Rationale: One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. A blood pressure of 136/88 mm Hg is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated, because the clot could be dislodged.
A client has a platelet count of 49,000/mL (49 × 10 /L). The nurse would instruct the client to avoid which activity? Ambulation Blowing the nose Visiting with children Eating fresh fruits and vegetables
Blowing the nose Rationale: Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse would instruct the client to avoid blowing the nose, because this activity can increase the risk of bleeding. Ambulation and visiting with children are not contraindicated with thrombocytopenia. Fresh fruits and vegetables are contraindicated for neutropenia, not thrombocytopenia.
The nurse would monitor postoperative clients for which clinical manifestation of a pulmonary embolus? Select all that apply. One, some, or all responses may be correct. Somnolence Dyspnea Hemoptysis Bronchial wheezes Feeling of impending doom
Dyspnea Hemoptysis Feeling of impending doom Rationale: Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus typically are apprehensive and hyperalert, not somnolent (the quality or state of being drowsy). Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders such as asthma.
Which action would the nurse take first when caring for a client with a possible pulmonary embolus? Auscultate the chest. Obtain the vital signs. Elevate the head of the bed. Notify the rapid response team.
Elevate the head of the bed Rationale: Elevating the head of the bed promotes better gas exchange by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. The nurse will auscultate the chest, but breath sounds are not initially changed with pulmonary embolus, which affects pulmonary circulation, but not ventilation. Heart rate and rhythm, blood pressure, and respiratory rate are likely to be affected by pulmonary embolism, but the nurse's first action would be to attempt to improve oxygenation by elevating the head of the bed. The rapid response team would be rapidly notified, but the initial action would be to elevate the head of the bed to improve oxygenation.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? Client reports stools are black. Oxygen saturation is 93%. Respiratory rate is 25 breaths per minute. Client has an ecchymosis on the ankle.
Client reports stools are black. Rationale: Because anticoagulant use increases the risk for gastrointestinal bleeding, the nurse would report the black-colored stools to the health care provider and anticipate action such as testing stools for occult blood, administration of protein pump inhibitor to decrease ulcer risk, and checking complete blood count. An oxygen saturation of 93% in a client with pulmonary embolus is acceptable. A slightly elevated respiratory rate in a client with a pulmonary embolus is a compensatory mechanism to prevent hypoxemia. Because low platelet counts increase risk for bleeding, an ecchymosis on this client's ankle would not be of high concern.
The nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. Which clinical finding requires the nurse to notify the primary health care provider? Lack of a productive cough 2 days postoperatively Rectal temperature of 100.2°F (37.9°C) 3 days postoperatively Complaints of right-sided chest pain 6 days postoperatively Fatigue in the leg on the unaffected side 5 days postoperatively
Complaints of right-sided chest pain 6 days postoperatively Rationale: Chest pain, along with dyspnea, cough, hemoptysis, and apprehension, is a classic sign of a pulmonary embolism. Six days postoperatively is a prime time for symptoms of a pulmonary embolus to occur, because decreased mobility promotes the development of deep vein thrombosis. The lack of a productive cough does not require nursing intervention; a productive, not nonproductive, cough indicates a respiratory infection requiring intervention. An increase in temperature can result from the inflammatory process; the temperature-regulating mechanisms in older adults may be compromised slightly, and they may show a slight elevation in body temperature for a longer period of time after surgery than a younger client. Weight bearing is being done by the unaffected leg at this time, and fatigue is expected.
Which action would the nurse take to prevent venous thrombus formation in a postoperative client? Select all that apply. One, some, or all responses may be correct. Encourage an increase in oral fluid intake. Massage the client's extremities with lotion. Instruct the client to avoid crossing the legs. Remind the client to dorsiflex the feet frequently. Help the client use prescribed pneumatic sequential stockings. Plan discharge teaching about the need to avoid taking aspirin.
Encourage an increase in oral fluid intake. Instruct the client to avoid crossing the legs. Remind the client to dorsiflex the feet frequently. Help the client use prescribed pneumatic sequential stockings Rationale: Actions such as increasing fluid intake, avoiding crossing the legs, frequent dorsiflexion of the feet, and using pneumatic sequential stockings when in bed all help decrease venous thrombus risk. Massage of the legs is avoided because it can dislodge any developing venous thrombus and cause a pulmonary embolus. Because aspirin helps prevent venous thrombosis, it does not have to be avoided after discharge.
Which nursing action would be planned to prevent thrombus formation for a client who had a total hip replacement? Turning the client from side to side Encouraging the client to perform ankle exercises Elevating the client's knee gatch 15 degrees Getting the client to sit in a chair for as long as tolerated
Encouraging the client to perform ankle exercises Rationale: Ankle movement, particularly dorsiflexion of the foot, allows muscle contraction, which compresses veins, reducing venous stasis and the risk for thrombus formation. Because the client is being turned, the client's muscles are not contracting to compress the veins and prevent venous stasis. The client must be turned at least every 2 hours to help prevent skin breakdown and pneumonia. Elevating the knee gatch will promote thrombus formation. Sitting for long periods is contraindicated, because pressure on the popliteal space and the dependent position of the lower extremities increase venous stasis
Which laboratory result would the nurse expect when reviewing the results for a client hospitalized with a chronic obstructive pulmonary disease exacerbation? Hematocrit 51% (0.51) Partial pressure of carbon dioxide (PaCO ) 28 mm Hg (3.72 kPa) Blood glucose 200 mg/dL (11.1 mmol/L) Serum potassium 3.4 mEq/L (3.4 mmol/L)
Hematocrit 51% (0.51) Rationale: Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen, leading to elevated hemoglobin and hematocrit or secondary polycythemia. PaCO would be expected to be elevated above the normal of 35 to 45 mm Hg (4.7-5.9 kPa) because of carbon dioxide retention. Blood glucose is not affected by chronic obstructive pulmonary disease. Serum potassium level is not affected by chronic obstructive pulmonary disease.
A client with a history of a herniated nucleus pulposus is scheduled for total hip replacement surgery. Which activity would the nurse encourage to prevent the most common complication associated with this type of surgery? Straight-leg raises Buerger-Allen exercises Deep breathing and coughing Plantar flexion and dorsiflexion
Plantar flexion and dorsiflexion Rationale: Plantar flexion and dorsiflexion exercises promote venous return, which helps prevent venous thrombus formation, the most common complication after hip surgery. Straight-leg raises are contraindicated for a client who has a history of a herniated nucleus pulposus. Buerger-Allen exercises stimulate collateral circulation for clients with peripheral vascular disease; they are seldom used, because walking is considered a more effective exercise. Although deep breathing and coughing should be encouraged to prevent respiratory complications, thrombus formation is a more common complication than respiratory complications after a total hip replacement.
Which action would the nurse take when a client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath? Suggest that the client call 911. Have the client take slow, deep breaths. Schedule the client to be seen in the clinic in 1 hour. Have the client take a low dose aspirin tablet immediately
Suggest that the client call 911. Rationale: The client's history and symptom of sudden onset dyspnea could be associated with multiple critical diagnoses (such as acute coronary syndrome or pulmonary embolism), which require rapid evaluation and treatment in the emergency department. Because the client has the potential for life-threatening diagnoses, encouragement of deep breathing is not an adequate response. The client needs immediate evaluation and possible intervention, so scheduling an appointment in an hour is not sufficient. Although the client may be experiencing acute coronary syndrome, there has been inadequate assessment of the etiology of the dyspnea, so taking an aspirin is not indicated.
A client sustains a crushing injury to the lower left leg, and a below-theknee amputation is performed. For which common clinical manifestation of a pulmonary embolus would the nurse assess for in this client? Select all that apply. One, some, or all responses may be correct. Sharp chest pain Acute onset of dyspnea Pain in the residual limb Absence of the popliteal pulse Blanching of the affected extremity
Sharp chest pain Acute onset of dyspnea Rationale: Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.
For which purpose would enoxaparin 40 mg subcutaneously daily be prescribed for a client who had abdominal surgery? To control postoperative fever To provide a constant source of mild analgesia To limit the postsurgical inflammatory response To provide prophylaxis against postoperative thrombus formation
To provide prophylaxis against postoperative thrombus formation Rationale: Enoxaparin, a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and of prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not an analgesic. Enoxaparin is not an anti-inflammatory medication.
