Thrombophlebitis, DVT and Embolus (final)

1 (elevate the head of the bed to facilitate breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The HCP must be kept informed of changes in the clients status but the priority in this case is alleviating the symptoms)

A client with DVT suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. elevate the head of the bed 2. encourage the client to cough and deep breathe 3. auscultate the lungs to detect abnormal breath sounds 4. contact the HCP

c (Rationale: DVT usually presents as leg and ankle edema, not as pain in the foot. Abdominal pain is not indicative of a leg DVT. The affected leg may or may not have pulses; this is not a good indicator of DVT. )

The nurse is assessing a 43-year-old postpartum woman. The nurse determines that the client may have a deep vein thrombosis (DVT) with which noted manifestation? a Pain located in the foot b Pain in the abdomen c Ankle and leg edema d Positive pulses in the affected leg

a (Rationale Considerations related to the development of DVT include complaints of leg or calf pain. A history of​ hypertension, joint replacement 5 years​ ago, and current diagnosis of osteoarthritis of the wrists do not increase the​ client's risk for developing a DVT.)

During a health history​ interview, the nurse is concerned that a client is experiencing signs of a developing DVT. Which information should cause this​ concern? a Current calf pain with walking b History of hypertension c Total hip replacement 5 years ago d Osteoarthritis of both wrists

b (Rationale: The client should be wearing antiembolism stockings as​ prescribed; this observation indicates that additional teaching is required. Taking warfarin as​ prescribed, elevating the​ legs, and frequent position changes indicate that teaching has been effective.)

During a home​ visit, the nurse evaluates care provided to a client recovering from a DVT. Which observation indicates that additional teaching is​ required? a The client is taking warfarin as prescribed. b The client has removed the antiembolism stockings. c The client is sitting with the legs elevated. d The client frequently changes position.

2 (compression devices and massage may dislodge a thrombus...The nurse may offer analgesics but the HCP should be notified asap)

Knee high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first? 1. Offer analgesics as prescribed, and apply compression devices 2. Leave the compression devices off, and contact the HCP to report the assessment findings 3. Massage the area of discomfort before applying the compression devices 4. Leave the compression devices off and report assessment findings to oncoming shift

a,b,c,e (Rationale: Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include measuring the calf and thigh diameter of the affected leg every​ shift; applying​ warm, moist heat to the affected extremity at least four times a​ day; encouraging​ range-of-motion exercises; and assisting with deep breathing and coughing. The legs should be​ elevated, not dependent.)

The nurse is planning care for a client with a DVT of the right calf. What should the nurse include in this​ client's plan of​ care? ​(Select all that​ apply.) a Encouraging​ range-of-motion exercises every 2 to 4 hours b Applying​ warm, moist heat to the affected area every 6 hours c Coaching to perform deep breathing and coughing every 2 hours d Assisting to a sitting position with the legs dependent every 4 hours e Measuring the calf and thigh diameter of the right leg every shift

d (Rationale: The client should be positioned to promote venous return. Flexing the hips promotes pooling of venous blood in the leg and impedes venous return. If ordered, elastic hose are worn 23 of 24 hours per day. When in a chair, the client should use a footstool or a recliner chair)

The nurse teaches the family of an older client who is at risk for developing deep vein thrombosis (DVT) about prevention of the condition. Which technique will the nurse include in the teaching? a Place pillows under the knees so that hips are flexed. b Apply elastic hose if swelling develops. c Keep feet squarely on the floor when sitting in a chair. d Position client to promote venous return.

a,b,c,e (​Rationale: When conducting the physical examination of a client with a​ DVT, assess body​ temperature, redness of the affected​ extremity, edema of the affected​ extremity, and the presence of warmth on palpation. Muscle atrophy is not a manifestation associated with a DVT.)

What is assessed during the physical examination of a client with a​ DVT? ​(Select all that​ apply.) a Edema of the affected extremity b Warmth on palpation c Body temperature d Muscle atrophy of the affected extremity e Redness of the affected extremity

c,d,e

Which is a risk factor for development of a​ DVT? ​(Select all that​ apply.) a Hypercholesterolemia b Diabetes mellitus c Immobilization d Lung cancer e Hormone therapy

4 (Heparin dosage is usually determined by the HCP based on the clients aPTT and INR lab values. Therefore the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin in contraindicated. Green leafy veges are high in Vit K and therefore are not recommended for clients receiving heparin. Monitoring the clients PT is done when the client is receiving warfarin sodium)

A client is admitted with a diagnosis of thrombophlebitis and DVT of the right leg. A loading dose of Heparin has been given in the ER., and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: 1. adminstering aspirin as prescribed 2. encouraging leafy green vegetables in the diet 3. monitoring the clients prothrombin time (PT) 4. monitoring the clients activated partial thromboplastin tims (aPTT) and international normalized ratio (INR)

4 (Based on the laboratory findings prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin and contact the HCP. The nurse should not administer the drug until the HCP has been contacted. The HCP not the pharmacy will make a decision about the dose of enoxaparin. The decision about administering the drug will be based on laboratory results , not evidence of bruising or bleeding.)

A client is being treated for DVT in the left femoral artery. The healthcare provider has prescribed 60 mg of enoxaparin SC. Before adminstering the drug, the nurse checks the clients laboratory results, noted below PTT 12.5 s INR 2.0 s Plt 50,000 Based on these results what should the nurse do? 1. Contact the pharmacist for a lower dose of the medication 2. Administer the medication as prescribed 3. Assess the client for signs of bruising on the extremities. 4. Withhold the dose of the medication and contact the HCP

4 (thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms are pain, swelling, and deep muscle tenderness. Air embolus is air entering a vein, FAT embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long bone fractures)

A client is on strict bed rest. The nurse should initiate measures to prevent which complication? 1. air embolus 2. fat embolus 3. stress fractures 4. thrombophlebitis

b (Rationale Duplex venous ultrasonography is a noninvasive test used to visualize the vein and measure the velocity of blood flow in the​ veins; although the clot often cannot be visualized​ directly, its presence can be inferred by an inability to compress the vein during the examination. Ascending contrast venography uses an injected contrast medium to assess venous thrombosis. Percutaneous transluminal angioplasty passes a balloon catheter through the​ skin, into the​ vessel, and through the vessel to the site of a​ lesion, where the tip of the catheter is inflated to expand the lumen of the vessel. Venous thrombectomy is a surgical procedure that removes thrombi to improve venous circulation and prevent pulmonary embolism or gangrene.)

A client is scheduled for a duplex venous ultrasonography to assist in the diagnosis of a DVT. What should the nurse instruct the client about this diagnostic​ test? ​a "Duplex venous ultrasonography removes thrombi to improve venous circulation and prevent pulmonary embolism or​ gangrene." ​b "Duplex venous ultrasonography measures changes in blood flow through the​ veins." ​c "Duplex venous ultrasonography uses an injected contrast medium to assess venous​ thrombosis." d ​"Duplex venous ultrasonography passes a balloon catheter through the​ skin, into the​ vessel, and through the vessel to the site of the​ lesion."

d

The nurse is caring for a client with a deep vein thrombosis (DVT) and selects ineffective tissue perfusion as a priority nursing diagnosis based on which assessment? a Mild, aching pain described by the client b Heart rate of 62 c Temperature of 102 degrees F d Pallor and coolness of the affected leg

2 (acute arterial occlusion is a sudden interuption of blood flow. The interruption can be the result of a complete or partial obstruction. Acute pain, loss of sensory and motor function, and a pale mottled numb extremity are the most dramatic and observable changes that indicate a life-threatening interruption in tissue perfusion. BP and HR changes may be associated with acute pain. Metabolic acidosis is a complication of irreversible ischemia. Swelling may result but may also indicate venous stasis or arterial insufficiency)

The nurse is caring for a client with venous thrombosis of the left lower leg. to prevent further tissue damage, it is important for the nurse to observe for which finding? 1. blood pressure and heart rate change 2. gradual or acute loss of sensory and motor function 3. metabolic acidosis 4. swelling in the left lower extremity

a,b,c,d (Rationale Manifestations of DVT include calf​ pain/tightness or​ dull, aching pain in the affected extremity that gets worse with​ walking; possible​ tenderness, swelling,​ warmth, and erythema along the affected​ vein; and edema and cyanosis of the affected extremity. Muscle twitching is not a manifestation of DVT.)

The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a pending​ DVT? ​(Select all that​ apply.) a Pale skin color of the left lower leg b Swelling of the left lower leg c Aching of the left calf d Area of redness along a left lower leg vein e Muscle twitching of the left thigh

b (Rationale: Women who smoke and use oral contraceptives have a major risk for DVT. Being 1 week postpartum is not a risk for DVT. Anticoagulant therapy is used to prevent DVT in the client recovering from a stroke. Since laparoscopic surgery reduces time in bed after surgery, the risk for DVT is very low. )

The nurse is conducting a teaching session at the community center about deep vein thrombosis (DVT). Which attendee at the session does the nurse determine is most at risk for developing DVT? a A 30-year-old client who is at 1 week postpartum b A 40-year-old client who smokes and uses oral contraceptives c A 63-year-old client post-CVA on anticoagulant therapy d A 41-year-old client who underwent a laparoscopic cholecystectomy

a,d (Rationale: Prophylactic measures that may prevent a DVT include elevating the feet with the knees slightly bent and practicing ankle flexion and extension exercises. Avoid pillows under the knees and crossing the legs. Limiting fluids and restricting caloric intake do not prevent development of a DVT.)

The nurse is planning care for a client who has been prescribed bed rest after abdominal surgery. Which action by the nurse helps to prevent development of a DVT in this​ client? ​(Select all that​ apply.) a Elevating the​ client's feet with the knees slightly bent b Placing a pillow under the​ client's knees c Limiting fluids and restricting caloric intake d Reviewing ankle extension and flexion exercises e Teaching the proper way to cross the legs

d (Rationale Warfarin​ (Coumadin) can cause bleeding even if the laboratory tests used to measure the effectiveness are in the therapeutic​ range; the healthcare provider must be notified of any bleeding so that the dosage can be adjusted. The client should use a​ soft-bristled toothbrush to prevent gum injury and bleeding. Warfarin can be taken at any time of​ day; however, it must be taken at the same time each day. Clients taking warfarin should not omit a dose without the healthcare​ provider's knowledge.)

The nurse is preparing discharge instructions for a client prescribed warfarin​ (Coumadin) for a DVT. What should the nurse include in this​ teaching? ​a "Take the warfarin at bedtime each​ day." ​b "Omit warfarin on the days when laboratory tests are​ ordered." c ​"Use a​ hard-bristled toothbrush." ​d "Notify the healthcare provider of bleeding or​ bruising."

b (Rationale Along with the expected immobilization associated with this​ injury, recent fracture of the femur places a client at high risk for DVT. Hypertension is not considered a direct risk factor for DVT. Diabetes mellitus and elevated cholesterol levels are risk factors for peripheral arterial disease.)

The nurse is reviewing assigned clients to determine which are at risk for developing a DVT. Which client should the nurse identify as a candidate for DVT preventive​ therapy? a The client with elevated cholesterol levels b The client with a recently fractured femur c The client with a history of diabetes mellitus d The client with a history of hypertension

b (Rationale Use of oral contraceptives places the client at increased risk for DVT. Being sedentary also increases the risk for DVT. There is no link between alcohol consumption and thrombosis in women who take oral contraceptives. A​ low-fat diet will not directly minimize the risk for​ DVT, and a high sodium intake is associated with hypertension in those taking oral contraceptives.)

The nurse is teaching a​ 25-year-old female client who is taking oral contraceptives. Which instruction should the nurse include to minimize the risk for developing a​ DVT? ​a "Consume a​ low-fat diet." b ​"Include periods of activity when​ traveling." ​c "Avoid high-sodium​ foods." d ​"Decrease your alcohol​ consumption.

a,c,e (Rationale: Women with varicose veins, high parity, and PIH are at increased risk for developing DVT. Prematurity and multiple births are not especially at risk for DVT. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analyzing)

The nurse on the postpartum unit is reviewing clients' charts. Which client will the nurse plan to monitor closely due to an increased risk for deep vein thrombosis (DVT)? The client with: (Select all that apply.) a Varicose veins b Prematurity c High parity d Multiple births e Pregnancy-induced hypertension (PIH)

a,c,d,e (Nursing diagnoses that may be appropriate for inclusion in the plan of care for a client with a DVT include impaired tissue​ perfusion, alterations in​ comfort, potential for ineffective​ protection, and Increased risk for impaired physical mobility. A DVT does not affect oxygenation.)

Which nursing diagnosis is used to guide the care for a client with a​ DVT? ​(Select all that​ apply.) a Potential for ineffective protection b Ineffective oxygenation c Increased risk for impaired physical mobility d Alterations in comfort e Impaired tissue perfusion

a,b,e (The Virchow triad involves blood​ stasis, increased blood​ coagulability, and vessel damage. An embolism is a vascular occlusion. Lysis is the dissolution or destruction of​ cells, the opposite of what happens when thrombi form.)

Which pathological​ factors, or parts of the Virchow​ triad, are associated with​ thrombophlebitis? ​(Select all that​ apply.) a Stasis of blood b Increased blood coagulability c Lysis d Embolism e Vessel damage

b,c,d (Duplex venous​ ultrasonography, magnetic resonance​ imaging, and plethysmography are used to diagnose a DVT.​ Color-flow Doppler ultrasound and magnetic resonance angiography are used to diagnose peripheral vascular disease.)

Which test is used to diagnose a​ DVT? ​(Select all that​ apply.) a ​Color-flow Doppler ultrasound b Plethysmography c Duplex venous ultrasonography d Magnetic resonance imaging e Magnetic resonance angiography

a (Rationale With this​ client's history of venous​ thrombosis, the healthcare provider would order an MRI to diagnose a thrombus in a pelvic vein. Ascending contrast venography assesses the location and extent of venous thrombosis. Plethysmography measures changes in blood flow through the veins. Duplex venous ultrasonography visualizes the vein and measures the velocity of blood flow.)

A client with a history of DVT reports a sudden onset of severe pain in the pelvis. Which diagnostic test should the nurse expect to be prescribed for this​ client? a Magnetic resonance imaging b Duplex venous ultrasonography c Ascending contrast venography d Plethysmography

1 ( a client with DVT is at high risk for a pulmonary embolism from an embolus traveling to the lung. Sudden onset of symptoms and worsening chest pain with a deep breath suggest a pulmonary embolism. The nurse assesses the client and obtains O2 sat levels prior to calling the HCP and administering morphine. ROM is a preventative measure for DVT and is not appropriate at this time)

A client with a recent diagnosis of DVT has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first: 1. assess the O2 sat 2. call the HCP 3. administer morphine sulfate, 2 mg IV 4. perform range of motion exercises in the involved leg

3 (thrombolytic agents such as streptokinase are used for clients with history of thrombus formation, CVA's, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or increase vascular permeability, nor do they prevent cerebral hemorrhage)

A client with cerebral embolus is receiving streptokinase. The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy? 1. improved cerebral perfusion 2, decreased vascular permeability 3. dissolved emboli 4. prevention of cerebral hemorrhage

d

Before receiving the morning​ report, the nurse makes rounds on assigned clients. At the bedside of one​ client, the nurse notes an ampule of vitamin K. What should the presence of this medication indicate to the​ nurse? a The client is receiving intravenous heparin. b The client is receiving​ low-molecular-weight heparin injections. c The client is receiving​ high-dose aspirin therapy. d The client is receiving warfarin.

d (Mrs. Kim already shows two of the three pathological​ factors, known as the Virchow​ triad, associated with venous​ thrombi: stasis of blood and symptoms of blood vessel damage. Increased blood coagulability is the third pathological factor associated with venous thrombi. Tissue hypoxia and anoxia are not pathological factors of​ DVT, and DVT does not affect blood pressure.)

Mrs.​ Kim, a​ 58-year-old client, is hospitalized with symptoms of DVT. The latest test results indicate stasis of​ blood, and the healthcare provider suspects that Mrs. Kim has developed venous thrombi. What other pathological factor should the nurse use to determine whether Mrs. Kim has a​ DVT? a Tissue hypoxia b Increased blood pressure c Tissue anoxia d Increased blood coagulability

b

Samuel​ Lewis, an​ 84-year-old client, is admitted for testing to rule out a DVT. While the nurse prepares an injection of​ low-molecular-weight heparin, Mr. Lewis asks why he needs injections in his stomach if the problem is in his leg. How should the nurse​ respond? ​a "Didn't your doctor tell you that you need to take these shots in your stomach for the rest of your​ life?" ​b "Low-molecular weight heparin prevents blood clots from forming in your leg but must be given in your​ stomach." ​c "People over the age of 80 should be receiving this medication in their stomach so that blood​ doesn't pool in the​ legs." ​d "This medication dissolves any clots in your legs but must be given in your​ stomach."

c ( Feedback Rationale: Anticoagulant therapy will continue after discharge, so understanding the importance of follow-up and monitoring for adverse effects is vital. Sitting in a straight chair is not recommended as it impairs venous return. Progressive exercise is recommended to promote venous return. While a low-cholesterol diet has health benefits, it will not prevent future episodes of DVT)

The nurse determines that teaching has been effective for a client with deep vein thrombosis (DVT) when which client statement is made? a "I'll use a hard-backed, upright chair instead of my recliner when sitting." b "I understand why I am not allowed to exercise for the next 6 weeks and will take it easy." c "I'll get my blood drawn as scheduled and notify my doctor if I have unusual bleeding or bruising." d "I'll have my partner buy a low-cholesterol cookbook and we'll visit a dietician for a low-cholesterol diet."

b,c,d,e (Actions to prevent development of a DVT include avoiding prolonged standing or​ sitting, avoiding leg​ crossing, and avoiding​ tight-fitting or binding garments and stockings. Avoiding extreme exercise does not prevent development of a DVT.)

Which action helps prevent development of a​ DVT? ​(Select all that​ apply.) a Avoiding extreme exercise b Avoiding prolonged sitting c Avoiding prolonged standing d Avoiding​ tight-fitting clothing or stockings e Avoiding crossing the legs

1,2,4,5,6 (blood in the urine is often one of the first signs of anticoagulant overdose. Fresh blood will be red, however blood in the urine may also be a dark smoky color. Daily ambulation is good to keep the venous blood circulating and prevent clots. Garlic and ginger INCREASE bleeding time and should not be used with anticoagulants. Clients who have had DVT should avoid activities that cause stagnation and pooling of blood. prolonged sitting coupled with change in air pressure without foot or leg excercises are activies that prevent venous return. Prevention measures are important because clients with DVT are at risk for pumonary emboli. )

Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having DVT? Select all that apply 1. check urine for bright blood and a dark smoky color 2. walk daily as a good excercise 3. use garlic and ginger, which may decrease bleeding time 4. perform foot/leg excercises and walking around the airplane cabin when on long flights 5. prevent DVT because of the risk of pulmonary emboli 6. avoid surface bumps because the skin is prone to injury

a,c,e (Rationale Risk factors for the development of a DVT include​ cancer, atrial​ fibrillation, and myocardial infarction. Use of​ over-the-counter medication for arthritis and having controlled type 2 diabetes mellitus are not risk factors for the development of this health problem.)

While conducting an​ assessment, the nurse determines that a client is at risk for developing a DVT. What did the nurse assess to make this​ conclusion? ​(Select all that​ apply.) a The client is being treated for bladder cancer. b The client is taking​ over-the-counter medication for arthritis. c The client has a history of atrial fibrillation. d The client controls type 2 diabetes mellitus with dietary intake and exercise. e The client experienced a myocardial infarction 2 years ago.