Chapter 26: Drugs Used to Treat Thromboembolic Disorders

4. Which way(s) describe(s) the action(s) of pharmacologic agents used to treat DVT? (Select all that apply.) a. Prevent platelet aggregation. b. Prevent the extension of existing clots. c. Inhibit steps in the fibrin clot formation cascade. d. Prolong bleeding time. e. Lower serum triglycerides.

ANS: A, B, C, D Agents used to treat DVT may prevent future clotting, may prevent the extension of clots, may inhibit steps in the formation of clots, and act to prolong bleeding time. Medications used to treat DVT do not lower serum triglyceride levels.

1. Which situation(s) will the use of anticoagulant therapy be anticipated? (Select all that apply.) a. To prevent stroke in patients at high risk b. Following a myocardial infarction c. Following total hip or knee joint replacement surgery d. With DVT e. To prevent thrombosis in immobilized patients f. Peptic ulcer disease

ANS: A, B, C, D, E Anticoagulant therapy is used to treat patients at high risk for stroke; patients with thromboembolic diseases, such as myocardial infarction; those at risk of developing thrombus resulting from underlying medical conditions or disease; and patients with thromboembolic diseases, such as DVT. Anticoagulant therapy is not used to treat patients with peptic ulcer disease.

2. Which important point(s) will the nurse include when preparing discharge education for a patient who will be receiving warfarin (Coumadin) at home? (Select all that apply.) a. Do not make any major changes to your diet without discussing it with your healthcare provider. b. Keep outpatient laboratory appointments for monitoring of therapy. c. Take the medication after meals. d. Report signs of bleeding to your healthcare provider, including observing skin for bruising; petechiae; blood in emesis, urine, or stools; bleeding gums; cold, clammy skin; faintness; or altered sensorium. e. Avoid aspirin products.

ANS: A, B, D, E Although patients on anticoagulant therapy should have knowledge about foods high in vitamin K (green, leafy vegetables), they should not make any major changes to their diet without consulting with their healthcare provider, pharmacist, and/or nutritionist. Patients receiving anticoagulant therapy should maintain regular appointments for assessment of the drug's therapeutic effects and follow up with the healthcare provider for regular review of laboratory values and dosage monitoring. Regular self-assessment for signs of bleeding is necessary for patients on anticoagulant therapy. Patients on anticoagulant therapy should avoid aspirin products. Warfarin does not have to be taken after meals.

6. Which rationale is accurate for administering fibrinolytic agents, such as streptokinase, within hours of the onset of myocardial infarction? a. Enhances myocardial oxygenation. b. Lyses the blood clot. c. Promotes platelet aggregation. d. Inhibits clotting mechanisms.

ANS: B Fibrinolytic agents such as streptokinase dissolve or lyse recently formed thrombi. The goals of thrombolytic therapy are to lyse the thrombus during the early stages of clot formation, restore circulation to the areas distal to the thrombus, and reduce morbidity after thromboembolism formation. Fibrinolytic agents do not have an effect on myocardial oxygenation and do not promote platelet aggregation or inhibit clotting mechanisms.

2. A patient receiving IV heparin therapy for a deep vein thrombosis (DVT) in his right calf asks why his calf remains painful, edematous, and warm to touch after 2 days of anticoagulant therapy. Which response by the nurse is most accurate? a. It takes at least 3 days for the symptoms to resolve once the clot dissolves. b. Heparin does not dissolve blood clots but neutralizes clotting factors, preventing extension of the clot and the possibility of it traveling elsewhere in your body. c. I will report this to your healthcare provider because there may be a need to look at alternative treatments. d. You appear anxious. The healthcare provider will eventually put you on ticlopidine, which allows for an earlier discharge.

ANS: B Heparin is used to treat a thromboembolism and promote neutralization of activated clotting factors, preventing the extension of thrombi and the formation of emboli. Heparin will minimize tissue damage by preventing it from developing into an insoluble, stable thrombus. It is inappropriate to tell a patient how long it will take to dissolve a clot. The patient's question does not warrant notification of the healthcare provider. Telling the patient that the healthcare provider will be starting the patient on ticlopidine is inappropriate and inaccurate

12. Which symptom is indicative of bleeding in a patient taking warfarin (Coumadin)? a. Bradycardia b. Petechiae c. Increased urinary output d. Dry skin

ANS: B Petechiae are indicative of bleeding. These pinpoint red spots on the skin indicate intradermal hemorrhage. Bradycardia, increased urinary output, and dry skin are not indicative of bleeding

4. Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-molecular-weight heparin product? a. Expel the air bubble from the prefilled syringe. b. Leave the needle in place for 10 seconds after injection. c. Administer the medication into the deltoid muscle. d. Massage the site after injection to increase absorption.

ANS: B The needle is left in place for 10 seconds after injection. Air is not expelled from the prefilled syringe. This medication is not administered intramuscularly. The site should not be massaged to increase absorption

9. Which action will the nurse implement to decrease the risk of clot formation in an older patient on bed rest? a. Assess peripheral pulses. b. Encourage passive leg exercises. c. Limit fluid intake. d. Position pillows behind the knees

ANS: B Using active or passive leg exercises for a patient on bed rest will prevent clot formation. Assessing pulses is not a preventive measure. Adequate hydration promotes fluidity of the blood and decreases the risk of clot formation. Placing pressure against the popliteal space will increase the risk of clot formation.

5. Which action(s) will be taken when preparing to administer dalteparin (Fragmin) to a patient in order to prevent DVT following a hip replacement? (Select all that apply.) a. Administer intramuscularly b. Inject slowly. c. Remove needle immediately after injection. d. Rub injection site following administration. e. Alternate injection sites every 24 hours.

ANS: B, E Dalteparin (Fragmin) should be injected slowly. Injection sites should be alternated every 24 hours. Dalteparin is administered by deep subcutaneous injection, not intramuscularly. Needle should be left in place for 10 seconds after injection. To minimize bruising, do not rub the injection site after completion of the injection.

8. Dipyridamole (Persantine) has been used extensively in combination with warfarin to prevent the formation of thromboembolism after which type of event? a. Myocardial infarction b. Transient ischemic attack c. Cardiac valve replacement d. Heart transplant

ANS: C Dipyridamole has been used extensively in combination with warfarin to prevent the formation of thromboembolism after cardiac valve replacement. Heparin is used to prevent clotting after myocardial infarction. Transient ischemic attacks are often treated with aspirin. Transplant patients are treated postoperatively with immunosuppressant medications

3. A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30 seconds. Which nursing intervention is most accurate? a. Document in the nursing notes that these results are within therapeutic range. b. Note the RBC count and wait for the healthcare provider to make the next round to discuss all laboratory values. c. Stop the heparin drip. d. Assess the patient for signs and symptoms of decreased sensorium

ANS: C Heparin dosage is considered to be in the normal therapeutic range if the aPTT is 1.5 to 2.5 times the control value. The patient's aPTT value is above the therapeutic range, which puts her at risk for hemorrhage. The most appropriate nursing action would be to stop the heparin drip. These results cannot be documented as being within the normal therapeutic range. RBC count and mental status are not relevant in assessing therapeutic response to anticoagulation.

14. Rivaroxaban (Xarelto) is ordered on a patient following knee replacement surgery. Which time period is accurate to convey when educating the patient on how long this treatment will continue? a. Only while hospitalized. b. For 35 days post surgically. c. For 12 days postsurgically. d. As long as creatinine clearance is less than 30.

ANS: C It is recommended that patients undergoing knee replacement continue treatment with rivaroxaban for 12 days postsurgically. It is recommended that patients undergoing hip replacement surgery continue treatment for 35 days postsurgically. Rivaroxaban should not be administered to patients with a creatinine clearance less than 30 mL/min.

1. A trauma patient arrives in the emergency department via EMS. He is bleeding profusely. A medical alert bracelet indicates that he is on heparin therapy. Which medication will the nurse most likely administer to counteract the action of heparin? a. Warfarin sodium (Coumadin) b. Enoxaparin (Lovenox) c. Protamine sulfate d. Vitamin K

ANS: C Protamine sulfate is the antidote to heparin. With the patient's risk of fluid volume deficit as a result of trauma, the primary intervention would be to counteract the effects of heparin to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract hemorrhage. Lovenox is chemically related to heparin and would not counteract hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin (Coumadin), not heparin

13. Which action will the nurse take when caring for a 27-year-old woman on the postpartum unit one day following a C-section to prevent clot formation? a. Position the patient with knees flexed. b. Initiate use of fitted thromboembolic disease deterrent (TED) stockings. c. Maintain complete bed rest. d. Implement deep breathing and coughing exercises.

ANS: D Deep breathing and coughing exercises should be part of regular postoperative nursing care to prevent clot formation. Knees should not be flexed. TED stockings require a physician's order. Early, regular ambulation should be encouraged after surgery

10. The nurse is teaching a patient about dietary implications while on warfarin (Coumadin) therapy. Which salad is highest in vitamin K? a. Fruit b. Pasta c. Potato d. Spinach

ANS: D Green leafy vegetables contain vitamin K.

11. Which statement by a patient recently prescribed warfarin (Coumadin) indicates the need for further teaching? a. I will always wear a medical alert bracelet. b. I will check with my healthcare provider before I take any OTC medications. c. I will be careful when I use a knife or other sharp objects. d. I will rinse my mouth with mouthwash instead of brushing my teeth.

ANS: D Soft-bristled toothbrushes are acceptable to use for oral care. Medical alert bracelets should always be worn. The healthcare provider needs to be consulted prior to taking any OTC medications. Caution must be used when cutting with knives or using any sharp objects.

7. Which mechanism of action applies to the use of drugs to treat thromboembolic disease? a. Dissolving clots and preventing formation of new clots b. Making platelets more flexible and preventing formation of new clots c. Causing vasodilation and increased blood flow d. Preventing platelet aggregation and inhibiting clot formation

ANS: D The pharmacologic agents used to treat thromboembolic disease act to prevent platelet aggregation or to inhibit a variety of steps in the fibrin clot formation cascade. Thromboembolic medications do not dissolve clots, make platelets more flexible, or cause vasodilation

5. A patient is receiving 1400 units of heparin/hr on an IV pump. The aPTT time is 54. The laboratory control is 25. Which action by the nurse is accurate? a. Bolus the patient with an additional 5000 units of heparin. b. Stop the heparin immediately and notify the healthcare provider that the patient's blood level is toxic. c. Administer protamine sulfate stat. d. Continue with the prescribed rate.

ANS: D Therapeutic heparin values are 1.5 to 2.5 times the control value. The therapeutic range of heparin with a control of 25 is 37.5 to 62.5 units/hr. A time of 54 is within the therapeutic range. An increase of heparin is not indicated because the patient is in the therapeutic range. The range is not toxic. An antidote to the anticoagulant is not indicated because the patient is within the therapeutic range

3. Which nursing intervention(s) would be accurate when administering heparin subcutaneously? (Select all that apply.) a. Assessment of recent aPTT levels b. Massaging the site after injection of medication c. Aspirating after needle insertion d. Documenting ecchymotic areas e. Monitoring of vital signs

ANS: D, E Ecchymosis, or bruising, indicates bleeding below the dermis and should be assessed closely. Patients on heparin therapy are prone to bleeding, which would lead to hemorrhagic shock. Vital sign alterations would alert the nurse to internal bleeding. aPTT levels are required to be monitored for the intravenous route but not for subcutaneous injections. The injection site should not be massaged to reduce local bleeding. Aspiration may cause bruising when administering heparin subcutaneously.