Sem 3 Clotting Adaptive

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply. A. Pain in the calf B. Intermittent claudication C. Redness in the affected area D. Pitting edema of the lower leg E. Ecchymotic areas around the ankle F. Localized warmth in the lower extremity

A, C, E Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease. Although some localized edema occurs, pitting edema does not occur in thrombophlebitis. Ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot.

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? A. Thermography B. Plethysmography C. Duplex venous doppler D. Somatosensory evoked potential

C. Duplex venous doppler Duplex venous doppler records an ultrasound of the veins, including blood flow abnormalities of the lower extremities, aiding detection of deep vein thrombosis. Thermography, which measures the heat radiating from the skin surface, is used to determine client response to antiinflammatory drug therapy and inflamed joints. Plethysmography is used to record variations in volume and pressure of blood passing through tissues; test is nonspecific. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease.

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client? A. Take a baby aspirin every day B. Ambulate early and frequently C. Sit for prolonged periods of time D. Place a warm soak on the legs daily

B. Ambulate early and frequently Early and frequent ambulation can help prevent thrombophlebitis. The nurse legally cannot recommend medications. Sitting for prolonged periods of time will increase the chance of thrombophlebitis. Warm soaks resolve inflammation; they do not prevent development of thrombophlebitis.

An adolescent is admitted with an acute hemophilia episode. For what are rest, ice, compression, and elevation most helpful? A. Encouraging immobilization B. Decreasing swelling and inflammation C. Providing pain relief and reducing anxiety D. Controlling bleeding and retaining joint function

D. Controlling bleeding and retaining joint function Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints. Reducing inflammation is not the goal of treatment for the hemophiliac process. Total immobilization is not required. Pain may be relieved to some degree but is not assured.

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer? A. Vitamin K B. Oprelvekin C. Warfarin sodium D. Protamine sulfate

D. Protamine sulfate Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.

A client with chronic liver disease reports, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. The nurse concludes that the client needs which additional supplement? A. Bile salts B. Folic acid C. Vitamin A D. Vitamin K

D. Vitamin K Fat-soluble vitamin K is essential for synthesis of prothrombin by the liver; a lack results in hypoprothrombinemia, inadequate coagulation, and hemorrhage. Although cirrhosis may interfere with production of bile, which contains the bilirubin needed for optimum absorption of vitamin K, the best and quickest manner to counteract the bleeding is to provide vitamin K intramuscularly. Folic acid is a coenzyme with vitamins B 12 and C in the formation of nucleic acids and heme; thus, a deficiency may lead to anemia, not bleeding. Vitamin A deficiency contributes to the development of polyneuritis and beriberi, not hemorrhage.

A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device? Record your answer using a whole number. ___ mL/hr

20 mL/hr

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply. A. Heparin B. Clopidogrel C. Warfarin D. Enoxaparin E. Acetylsalicylic acid

A, D Heparin may be used during pregnancy because it does not cross the placental barrier and will not cause hemorrhage in the fetus. Enoxaparin does not cross the placental barrier; its classification for pregnancy is B. Clopidogrel is a platelet aggregation inhibitor. It is not used for thrombophlebitis; it is used to reduce the risk of brain attack, transient ischemic attack, unstable angina, and myocardial infarction. Warfarin crosses the placental barrier, causing hemorrhage in the fetus. Acetylsalicylic acid is a platelet aggregation inhibitor and is not recommended during pregnancy (D category).

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply. A. Avoid intramuscular injection B. Institute neutropenic precautions C. Monitor the white blood cell count D. Administer prescribed anticoagulants E. Examine the skin for ecchymotic areas

A, E Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrombocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.

The blood lab work for a client with purpuric lesions on the skin shows a thrombocyte count of 100,000 cells per microliter. Which nursing intervention would be priority in this patient to reduce the risk of bleeding? A. Advising the client to drink plenty of fluids B. Advising the client to perform bending exercises C. Advising the client to use superabsorbent tampons D. Advising the client to use alcohol-based mouthwashes

A. Advising the client to drink plenty of fluids A client with purpuric lesions and a thrombocyte count of 100,000 cells per microliter has thrombocytopenia. Drinking plenty of fluids helps to prevent constipation and straining while having a bowel movement, thereby preventing bleeding. Performing bending exercises may lead to bleeding from the nose, and it is contraindicated. Usage of superabsorbent tampons may increase the chance of toxic shock syndrome (TSS) and result in severe infection or death. Usage of alcohol-based mouthwashes can dry the gums and increase bleeding.

A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia? A. Avoid traumatic injuries and exposure to infection B. Perform frequent mouth care with a firm toothbrush C. Increase oral fluid intake to a minimum of 3 L daily D. Report any unusual muscle cramps or tingling sensations in the extremities

A. Avoid traumatic injuries and exposure to infection Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. Aggressive oral hygiene can precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. Muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client? A. Edema of the left leg B. Mobility of the left leg C. Positive left-sided Babinski reflex D. Presence of left arterial peripheral pulse

A. Edema of the left leg Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return. Difficulty with mobility occurs with musculoskeletal or neuromuscular problems. Positive left-sided Babinski reflex is associated with neurologic deficits in the corticospinal tracts. Presence of a left arterial peripheral pulse is made to determine the status of the arterial, not venous, system.

The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding? A. Joints B. Abdomen C. Cerebrum D. Epiphyses

A. Joints Activity can result in bleeding in children with hemophilia; therefore weight-bearing joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from the trauma of direct force. The cerebrum is protected by the skull and is not likely to be injured. Bleeding from bones themselves is not common without other associated trauma.

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? A. Prevents extension of the clot B. Reduces the size of the thrombus C. Dissolves the blood clot in the vein D. Facilitates the absorption of red blood cells

A. Prevents extension of the clot 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 client is at greatest risk for the development of a venous thrombosis? A. A 76-year-old female with a 100-pack-per-year smoking history and hypertension B. A 68-year-old male on bed rest following a left hip fracture C. A 59-year-old male who is an intravenous drug user with hyperlipidemia D. A 42-year-old female with Factor V Leiden mutation on warfarin

B. A 68-year-old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

A lactating woman has developed thromboembolism. Which drug should be prescribed if she wishes to continue breast-feeding? A. aspirin B. Heparin C. Dicumarol D. Phenindione

B. Heparin Heparin is the drug of choice to treat thromboembolism in a lactating woman because it is not absorbed in the breast milk. Aspirin may cause severe bleeding so is not preferred. Dicumarol may cause a hemorrhage and therefore is not preferred. Phenindione may cause a bruising effect and therefore is not the drug of choice.

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A. Pregnancy B. Inactivity C. Aerobic exercise D. Tight clothing

B. Inactivity 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.

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? A. Increase the IV rate of heparin B. Interrupt the infusion and notify the primary healthcare provider of the aPTT result C. Document the result on the medical record and recheck the aPTT in 4 hours D. Call the primary healthcare provider to obtain a prescription for a low-molecular-weight heparin

B. Interrupt the infusion and notify the primary healthcare provider of the aPTT result The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary healthcare provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding? A. Brain B. Joints C. Kidneys D. Abdomen

B. Joints The joints are the most commonly involved areas because of weight bearing and constant movement. Neither the brain, nor the kidneys, nor the abdomen is the most common site; however, bleeding may occur in any of these areas.

A 10-year-old child is found to have hemophilia. The nurse is explaining how hemophilia is inherited. What is the best explanation of the genetic factor that is involved? A. It follows the Mendelian law of inherited disorders B. The mother is a carrier of the disorder but is not affected by it C. It is an autosomal dominant disorder in which the woman carries the trait D. A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier

B. The mother is a carrier of the disorder but is not affected by it The hemophilia gene is carried on the X chromosome but is recessive. Therefore the female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Females only carry the trait; usually males are affected.