MyLab M. 16.4 Deep Venous Thrombosis
The nurse is discharging an 89-year-old patient who is wheelchair bound and who has been receiving heparin therapy. Which order should the nurse anticipate? ANSWER Discontinue heparin. Transition from heparin therapy to warfarin. Continue heparin therapy. Place pillows under the knees to ensure the knees remain sharply flexed.
Discontinue heparin.
A patient with deep vein thrombosis (DVT) has been diagnosed with a pulmonary embolism (PE). Which nursing intervention promotes effective gas exchange? ANSWER Encouraging increased mobility Elevating the head of the bed Encouraging diversional activities, such as reading a book Elevating the feet 15-20 degrees
Elevating the head of the bed
The nurse is caring for a patient who is at 1 week postpartum and reports tenderness and swelling in their left lower leg. Which additional factor is associated with thrombophlebitis? ANSWER Decreased platelets and fibrin Embolism Increased blood coagulability Lysis
Increased blood coagulability
When laboratory tests indicate that a patient has circulatory stasis, the nurse suspects that the patient has a deep venous thrombosis (DVT). Which additional pathologic factor supports the nurse's suspicion? ANSWER Tissue anoxia Increased blood pressure Increased blood coagulability Tissue hypoxia
Increased blood coagulability
The nurse is preparing to administer low molecular weight heparin (LMWH) subcutaneously. The nurse understands which statement to be accurate? ANSWER LMWH prevents blood clots from forming. All people over the age of 80 should receive LMWH as deep venous thrombosis (DVT) prophylaxis. The medication dissolves clots in the legs. Patients receiving this medication will need to take it for the rest of their life.
LMWH prevents blood clots from forming.
A middle-aged patient has a history of deep venous thrombosis (DVT). Which manifestation should the nurse identify as most likely to be a complication from the DVT? ANSWER Pain and edema in the affected leg Hypotension Circulatory stasis in the unaffected leg Hypercoagulability
Pain and edema in the affected leg
The nurse is preparing discharge instructions for a patient prescribed warfarin for a deep venous thrombosis. Which instruction should the nurse include? "Use a hard-bristle toothbrush." "Notify the healthcare provider of bleeding or bruising." "Omit warfarin on the days when laboratory tests are ordered." "Take the warfarin at bedtime each day."
"Notify the healthcare provider of bleeding or bruising."
The nurse is caring for an older adult patient diagnosed with deep venous thrombosis (DVT). Which statement is accurate regarding the older adult and DVT? ANSWER "Older adult patients diagnosed with DVT are often asymptomatic." "Older adult patients diagnosed with DVT often have swelling of the unaffected extremity." "Older adult patients diagnosed with DVT often have dull, aching pain in the unaffected extremity when walking." "Older adult patients diagnosed with DVT often have increased capillary refill in the affected extremity."
"Older adult patients diagnosed with DVT are often asymptomatic."
While the nurse prepares an injection of an anticoagulant, the 82-year-old patient asks why injections will be given in the stomach if the problem is in the leg. Which response by the nurse is accurate? ANSWER "People over the age of 80 should be receiving this medication in their stomach so that blood doesn't pool in the legs." "This medication dissolves any clots in your legs but must be given under the skin to be absorbed." "Didn't your healthcare provider tell you that you need to take these shots in your stomach for the rest of your life?" "This medication prevents blood clots from forming in your leg but must be given under the skin to be absorbed."
"This medication prevents blood clots from forming in your leg but must be given under the skin to be absorbed."
The nurse is caring for a patient with a history of deep venous thrombosis (DVT) who is scheduled for a total hip replacement. Which assessment question is a priority for the nurse? ANSWER "Can you show me how far you can bend your legs?" "What medications are you currently taking?" "Do you have any swelling in your legs?" "Do you have calf pain when walking?"
"What medications are you currently taking?"
Which patient is at the greatest risk for developing a DVT? ANSWER A 17-year-old woman using hormonal contraception A 3-year-old born via cesarean section at full term A 65-year-old jogger A 15-year-old football player
A 17-year-old woman using hormonal contraception
The nurse is discussing the care of a patient with a colleague. The patient, who reports pain in the affected extremity, is being treated for deep vein thrombosis (DVT). Which statement by the colleague indicates a need for further teaching? ANSWER "An increase in pain may be caused by extension of the thrombosis." "Swelling places pressure on pain receptors." "Inflammed tissue releases substances that stimulate pain receptors." "As the thrombosis dissolves, pain may increase."
"As the thrombosis dissolves, pain may increase."
The nurse is teaching a 25-year-old woman who is taking oral contraceptives. Which instruction should the nurse include to minimize the risk for developing a deep venous thrombosis (DVT)? ANSWER "Avoid high-sodium foods." "Decrease your alcohol consumption." "Include periods of activity when traveling." "Consume a low-fat diet."
"Include periods of activity when traveling."
A patient is scheduled for a duplex venous ultrasonography to assist in the diagnosis of a deep venous thrombosis (DVT). Which information should the nurse provide to the patient regarding this diagnostic test? ANSWER "A balloon catheter is inserted through the blood vessel to the site of the lesion." "An injected contrast medium is used to assess venous thrombosis." "The velocity of blood flow through the veins is measured." "Thrombi are removed to improve venous circulation and prevent pulmonary embolism."
"The velocity of blood flow through the veins is measured."
During a health history interview, the nurse is concerned that a patient is experiencing signs of a developing deep venous thrombosis (DVT). Which information should lead the nurse to make this deduction? ANSWER Current calf pain with walking Osteoarthritis of both wrists Total hip replacement 5 years ago History of hypertension
Current calf pain with walking
The nurse is assessing an 83-year-old patient. Which finding should concern the nurse the most? ANSWER History of hypertension Osteoarthritis of both wrists Current calf pain with walking Total hip replacement 5 years ago
Current calf pain with walking
The nurse is assessing a patient who recently started warfarin. Which patient statement requires follow-up? "I will stay on warfarin for at least 3 months." "I will continue taking heparin for a few days because the full effect of warfarin is delayed." "I will need to follow up with my healthcare provider regularly." "I take gingko supplements for cognition."
"I take gingko supplements for cognition."
A 50-year-old patient is being discharged after treatment for a deep venous thrombosis (DVT). Which instruction should the nurse provide to the patient to reduce the risk of future DVT development? ANSWER "Take frequent breaks to prevent sitting for prolonged periods of time." "It is best to stand and wear tight-fitting hose when working." "Standing is preferred over sitting, so think about altering your work environment." "Sitting is permitted as long as the legs are not crossed."
"Take frequent breaks to prevent sitting for prolonged periods of time."
A patient with a history of deep venous thrombosis reports a sudden onset of severe pain in the pelvis. Which diagnostic test should the nurse expect to be prescribed for this patient? ANSWER Magnetic resonance imaging (MRI) Duplex venous ultrasonography Plethysmography Ascending contrast venography
Magnetic resonance imaging (MRI)
The nurse is caring for a patient at 24 weeks' gestation who presents with tachycardia, tachypnea, and pain and swelling in the left lower extremity. Following confirmation of the suspected diagnosis, which collaborative therapy should the nurse anticipate? ANSWER Begin warfarin therapy. Apply a sequential compression device. Instruct the patient of the need to avoid breastfeeding after delivery. Begin heparin therapy.
Begin heparin therapy.
The nurse is caring for a patient admitted with a diagnosis of deep venous thrombosis (DVT). Which measure should the nurse implement to relieve symptoms and reduce inflammation? Apply cold compresses for 20 minutes every 2 hours. Avoid tight-fitting garments or stockings that bind. Encourage the patient to ambulate every 4 hours while awake. Elevate the head of the bed and ensure the knees remain straight.
Avoid tight-fitting garments or stockings that bind.
The nurse is caring for a 2-year-old patient with a diagnosis of deep venous thrombosis. Which collaborative therapy should the nurse anticipate giving immediately? ANSWER Oral warfarin IV heparin Factor Xa inhibitor Low molecular weight heparin
Low molecular weight heparin
A patient has been treated for deep venous thrombosis (DVT) conservatively with anticoagulant therapy with little results. Which is an indication for a venous thrombectomy? ANSWER Atrial fibrillation Multiple thrombi lodged in femoral vein Recurrent DVTs Superficial thrombophlebitis in the great saphenous vein
Multiple thrombi lodged in femoral vein
The nurse is caring for an older adult patient diagnosed with deep venous thrombosis. Which clinical manifestation should the nurse expect the patient to exhibit? ANSWER Swelling of the unaffected leg Dull, aching pain in the unaffected leg No symptoms Increased capillary refill in the affected leg
No symptoms
The nurse is assessing a patient with deep vein thrombosis (DVT) who reports shortness of breath and chest pain. The nurse notes the patient has rapid, shallow breathing, and an oxygen saturation of 89%. Which intervention should the nurse implement immediately? ANSWER Ambulating the patient Getting the patient ot of bed Raising the head of the bed Placing the patient's legs on a pillow
Raising the head of the bed
The nurse is assessing a patient with a suspected deep vein thrombosis (DVT). Which event should the nurse not consider associated with this diagnosis? ANSWER Recent hospitalization Recent lengthy surgery Immobilization Running a marathon
Running a marathon
The nurse is planning care for a patient who has been prescribed bedrest after abdominal surgery. Which action by the nurse helps to prevent development of a deep venous thrombosis (DVT) in this patient? ANSWER Placing a pillow under the patient's knees Teaching the proper way to cross the legs Teaching ankle extension and flexion exercises Limiting fluids and restricting caloric intake
Teaching ankle extension and flexion exercises
The home care nurse is evaluating a patient who was recently discharged from the hospital for deep venous thrombosis (DVT). Which observation indicates that additional teaching is required? ANSWER The patient is taking an anticoagulant as prescribed. The patient frequently changes position. The patient is sitting with the legs elevated. The patient has removed the antiembolism stockings.
The patient has removed the antiembolism stockings.
While making rounds on assigned patients, the nurse notes an ampule of vitamin K at the bedside of one patient. Which should the nurse understand from the presence of this medication? ANSWER The patient is receiving warfarin. The patient is receiving low molecular weight heparin injections. The patient is receiving intravenous heparin. The patient is receiving high-dose aspirin therapy.
The patient is receiving warfarin.
The nurse reviews the care plan for a patient with a diagnosis of deep venous thrombosis (DVT). Which item in the plan of care should the nurse question? ANSWER Legs will be elevated with knees slightly flexed. The patient will wear antiembolism stockings while on bedrest. The patient will remain on strict bedrest. Warm, moist compresses will be applied over the affected vein.
The patient will wear antiembolism stockings while on bedrest.
The nurse is reviewing assigned patients to determine who is at risk for developing a deep venous thrombosis (DVT). Which patient should the nurse identify as a candidate for DVT preventive therapy? ANSWER The patient with a recently fractured femur The patient with elevated cholesterol levels The patient with a history of diabetes mellitus The patient with a history of hypertension
The patient with a recently fractured femur
