Chapter 48: PrepU
A client is discharged from the hospital with a prescription for warfarin. Which statement by the client indicates successful client teaching? "I will discontinue my other medications." "I will avoid ginseng and St. John's wort." "I will eat plenty of spinach or broccoli daily." "I'll stop taking vitamin C supplements."
"I will avoid ginseng and St. John's wort." Many commonly used herbs and supplements have a profound effect on drugs for anticoagulation, including St. John's wort and ginseng. The client should avoid green leafy vegetables due to vitamin K. The client should not discontinue their medications without first consulting with the primary health care provider. Vitamin C does not interfere with anticoagulant therapy.
The nurse educates a client diagnosed with atrial fibrillation about the prescribed warfarin. Which client statements establish the need for further clarification? "I will stop eating green leafy vegetables, broccoli, yogurt, or cheese." "I will take the warfarin at the same time each day." "I will not drink alcohol unless it is all right with my primary care provider." "I will keep my lab appointments for prothrombin and INR levels."
"I will not eat green leafy vegetables, broccoli, yogurt, or cheese." The nurse needs to clarify teaching regarding the intake of foods rich in Vitamin K. The client should not avoid eating foods with Vitamin K, but eat consistent amounts every day so therapeutic levels for the warfarin may be maintained. The client has an adequate understanding of the importance of keeping lab appointments for PT and INR levels used to monitor and regulate the warfarin dosage. The client should take the warfarin the same tie each day to maintain consistent blood levels of the drug. The client should not drink alcohol unless the primary care provider approves it, and instructs the client as to how much and how often. Alcohol will increase the risk for bleeding.
The nurse determines that additional client teaching is needed regarding anticoagulants when the client makes which statement? "I'll use disposable razors to shave and use each razor only once." "I'll start wearing a medical alert bracelet indicating my diagnosis." "I'll use acetaminophen if I experience arthritis pain." "I plan to report to the laboratory for my follow-up blood work."
"I'll use disposable razors to shave and use each razor only once." The client should use an electric razor to shave rather than a disposable razor that could nick the skin and increase the risk of bleeding. Wearing a medical alert bracelet, getting regular follow-up lab work, and use of acetaminophen would all be appropriate actions that would not indicate the need for further teaching.
The health care provider reorders dalteparin for the client. The pharmacy states that the drug is not available. The nurse calls the health care provider and asks if dalteparin can be replaced with another LMWH. What does the nurse expect to be the response? "The drugs are not interchangeable; have the pharmacy obtain the drug ordered." "I'll change the drug to Lovenox." "The drugs are interchangeable; the pharmacy can substitute another LMWH." "I'll change the order to enoxaparin."
"The drugs are not interchangeable; have the pharmacy obtain the drug ordered." Currently available LMWHs (dalteparin, enoxaparin) differ from standard heparin and each other and are not interchangeable.
A client recovering from joint replacement surgery is prescribed subcutaneous heparin injections. Which response will the nurse make when the client asks if the medication can be taken orally? "The gastrointestinal tract does not absorb the drug, so it cannot be given by mouth." "It will take too long for the medication to work if it is given by mouth." "The medication has to be given through an injection because your activity status is limited." "The medication needs to be given by injection because of the type of surgery that you had."
"The gastrointestinal tract does not absorb the drug, so it cannot be given by mouth." It is necessary to give heparin intravenously or through subcutaneous injection because the gastrointestinal tract does not absorb the drug. There is not an oral form of heparin.
A client asks the nurse what dose of acetylsalicylic acid (aspirin) is needed for antiplatelet effects to prevent heart attacks. What dose is most appropriate to reduce platelet aggregation? 1000 mg 300 mg 10 mg 625 mg
300 mg A single dose of 300 to 600 mg or multiple doses of 30 mg inhibit cyclooxygenase in circulating platelets almost completely. The dose of 100 mg is too small. The doses of 625 mg and 1000 mg are too large.
A nurse will use extreme caution when administering heparin to which patient? A 56-year-old male who smokes and drinks alcohol occasionally A 22-year-old female with urticaria A 54-year-old female with accelerated heart rate A 38-year-old male with peptic ulcer disease
A 38-year-old male with peptic ulcer disease Heparin should be administered with extreme caution to patients with peptic ulcer or liver disease or after surgery because those patients would have greater risk for hemorrhage or excessive blood loss. Urticaria is a listed adverse effect of taking heparin and would therefore be expected. A patient who takes heparin would be advised to not drink heavily or smoke, but neither would have the safety risk posed by a patient with peptic ulcer. A patient with an accelerated heart rate and on heparin therapy would be at no special risk.
A 55-year-old client has been diagnosed with coronary artery disease and begun antiplatelet therapy. The client has asked the nurse why a "blood thinner like warfarin" hasn't been prescribed. What is the most likely rationale for the clinician's use of an antiplatelet agent rather than an anticoagulant? Antiplatelet agents do not require the client to undergo frequent blood work; anticoagulants require constant blood work to ensure safety. Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis. Antiplatelet agents have fewer adverse effects than anticoagulants. Antiplatelet agents are most effective in large vessels; anticoagulants are most effective in the small vessels of the peripheral circulation.
Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis. Anticoagulants are more effective in preventing venous thrombosis than arterial thrombosis. Antiplatelet drugs are used to prevent arterial thrombosis. CAD has an arterial rather than venous etiology. The rationale for the use of antiplatelet agents in CAD is not likely related to the need for blood work or the presence of adverse effects.
A nurse is conducting a seminar on thrombosis. The nurse should point out that arterial thrombus can occur related to which situation? Decreased blood flow Arrhythmias Injury to the vessel wall Altered blood coagulation
Arrhythmias The nurse should mention that arterial thrombosis is caused by atherosclerosis and arrhythmias. Decreased blood flow, injury to the vessel wall, and altered blood flow are causes of venous thrombosis.
A nurse is caring for a patient receiving the anticoagulant drug warfarin. What pre-administration assessments should the nurse perform before administering the drug to the patient? Observe for signs of thrombus formation. Assess prothrombin time (PT) and INR. Assess for signs of bleeding. Monitor for hypersensitivity reaction.
Assess prothrombin time (PT) and INR. The nurse should assess the prothrombin time (PT) and INR before administering the anticoagulant drug warfarin to the patient. Observing for signs of thrombus formation, assessing for signs of bleeding, and monitoring for hypersensitivity reaction are the ongoing assessments performed in patients who are administered warfarin.
A 60-year-old client experienced a sudden onset of chest pain and shortness of breath and was subsequently diagnosed with a pulmonary embolism in the emergency department. The client has been started on an intravenous heparin infusion. How does this drug achieve therapeutic effect? By inhibiting the action of vitamin K at its sites of action By inactivating clotting factors and thus stopping the coagulation cascade By promoting the rapid excretion of vitamin K by the gastrointestinal mucosa By inhibiting platelet aggregation on vessel walls and promoting fibrinolysis
By inactivating clotting factors and thus stopping the coagulation cascade Heparin, along with antithrombin, rapidly promotes the inactivation of factor X, which, in turn, prevents the conversion of prothrombin to thrombin. Heparin does not achieve its therapeutic effect through the excretion or inhibition of vitamin K or by inhibiting platelet aggregation.
An older adult client with a history of mild renal failure has experienced two different transient ischemic attacks (TIAs) and has been prescribed clopidogrel therapy. What statement should be the basis of the nurse's response when asked why aspirin (ASA) wasn't prescribed as the drug of choice? Clopidogrel is better suited for older clients with renal impairment. Aspirin is very irritating to the stomach. Clopidogrel is believed to be more effective than aspirin in treating TIAs. Aspirin is not effective in treating TIAs.
Clopidogrel is believed to be more effective than aspirin in treating TIAs. Aspirin has long been the most widely used antiplatelet drug for prevention of myocardial reinfarction and arterial thrombosis in clients with TIAs and prosthetic heart valves. However, clopidogrel may be more effective than aspirin. While ASA can cause stomach irritation, that is not the reason it is not the drug of choice for this client. Because clopidogrel is metabolized in the liver, it may accumulate in people with hepatic impairment, but there is currently no contraindication in clients with renal failure.
A client is prescribed warfarin. The client also takes a diuretic for the treatment of cardiac problems. The nurse will monitor the client for which potential interaction? Increased effectiveness of the diuretic Decreased effectiveness of the anticoagulant Increased absorption of the diuretic Increased absorption of the anticoagulant
Decreased effectiveness of the anticoagulant The nurse should monitor for decreased effectiveness of warfarin as an effect of the interaction between the anticoagulant and the diuretic. The nurse need not monitor for the increased effectiveness of the diuretic, the increased absorption of the anticoagulant, or the increased absorption of the diuretic in the client.
A client is admitted with thrombophlebitis and sent home on enoxaparin therapy. Which statement indicates a good understanding of why enoxaparin is being administered? Enoxaparin decreases the viscosity of blood. Enoxaparin will dissolve the clots. Enoxaparin eliminates certain clotting factors. Enoxaparin inhibits the formation of additional clots.
Enoxaparin inhibits the formation of additional clots. Low-molecular-weight heparins (LMWH) prevent the development of additional clots. They do not eliminate clotting factors. LMWHs do not prevent the blood from clotting. LMWHs do not dissolve the clot.
The nurse is teaching a client about dietary concerns related to the administration of warfarin. The nurse determines the teaching session is successful when the client correctly points out that a consistent intake of which foods is necessary when using warfarin? Root vegetables Green leafy vegetables Dairy products Fruits and cereals
Green leafy vegetables The client should be aware that foods high in vitamin K can affect the effectiveness of warfarin. These foods include leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt. Increased amounts of vitamin K could decrease the PT/INR and increase the risk of clot formation. Dairy products, root vegetables, fruits, and cereals are generally low in vitamin K. A diet that is very low in vitamin K may prolong the PT/INR and increase the risk of hemorrhage. The key to vitamin K management for clients receiving warfarin is maintaining a consistent daily intake of vitamin K. To avoid large fluctuations in vitamin K intake, clients receiving warfarin should be aware of the vitamin K content of food.
The nurse is preparing to administer protamine emergently to a client per instructions from the health care provider. The nurse concludes this is necessary due to an adverse reaction to which drug? Clopidogrel Alteplase Warfarin Heparin
Heparin An overdosage of any anticoagulant may result in uncontrolled bleeding in the client. In most cases, discontinuation of the drug is usually sufficient to correct overdosage; however, if the bleeding is severe there are antidotes. Protamine is used to treat overdose of heparin and low-molecular-weight heparins (LMWHs). Vitamin K is used to treat the overdosage of warfarin. Alteplase and clopidogrel do not require antidotes.
Mr. Hon has been admitted to the hospital and placed on anticoagulant therapy. For what blood-related disorder is this therapy used? Hemophilia Hypercoagulation Blood cancer Hemostasis SUBMIT ANSWER
Hypercoagulation Anticoagulants are used to treat hypercoagulation, or excessive coagulation. They prevent the blood from clotting unexpectedly and maintain the flow of blood. Hemophilia is treated with human factor IX complex. Blood cancer is treated with therapies such as chemotherapy or radiation treatment. On the other hand, hemostasis is the process by which the body prevents excessive blood flow during an injury.
A 75-year-old client presents to the health care provider's office with bleeding gums and multiple bruises. When the nurse reviews the client's drug history, the nurse finds that the client is prescribed aspirin 81 mg/d. What drug may cause increased bleeding when used in conjunction with the aspirin? Antihypertensives Antibiotics Antiarrhythmics NSAIDs
NSAIDs NSAIDs, which are commonly used by older adults, also have antiplatelet effects. Clients who take an NSAID daily may not need low-dose aspirin for antithrombotic effects.
A client is taking warfarin to prevent clot formation related to atrial fibrillation. How are the effects of the warfarin monitored? Platelet count PT and INR RBC aPTT
PT and INR The warfarin dose is regulated according to the INR. The INR is based on the prothrombin time. The red blood cell count is not indicative of warfarin dosage. The aPTT is utilized to determine heparin dose. The platelet count is required to determine warfarin dose.
What values are used to monitor the effectiveness of warfarin therapy? PT and INR Platelet count RBC aPTT
PT and INR Warfarin dose is regulated according to the international normalized ratio (INR), which is based on prothrombin time (PT). PT and INR are assessed daily until a stable daily dose is reached. Thereafter, PT and INR are determined every few weeks for the duration of warfarin therapy.
A client is receiving heparin. Which would the nurse use to monitor the effects of the drug? Vitamin K level International normalized ratio Partial thromboplastin time Prothrombin time
Partial thromboplastin time Heparin's effectiveness is monitored by the results of the partial thromboplastin time. The INR and PT are used to monitor warfarin. Vitamin K is the antidote for warfarin, and levels are not monitored to evaluate the effects of any anticoagulant.
A male client is receiving heparin by continuous intravenous infusion. The nurse will instruct the client and family members to report what should it occur? Presence of blood in urine or stools Sudden occurrence of sleepiness and drowsiness A skin rash Dizziness
Presence of blood in urine or stools The nurse should instruct the client and family members to report the presence of blood in urine or stools and any bleeding from the gums, nose, vagina, or wounds. The anticoagulation properties of heparin can sometimes result in abnormal bleeding. Sleepiness, drowsiness, skin rash, and dizziness are not commonly identified adverse effects of the drug.
The health care provider discovers a clot in the client's left lower leg. Anticoagulant drugs are prescribed to prevent formation of new clots and to achieve which other effect? Increase coagulation Regulate PT, INR Regulate PTT Prevent extension of clots already present
Prevent extension of clots already present Anticoagulant drugs are given to prevent formation of new clots and extension of clots already present.
A nurse is conducting an assessment on a client who has recently undergone exploratory laparotomy. The nurse notes the continued order for enoxaparin. The nurse predicts this is to accomplish which goal? Prevent formation of a blood clot Encourage cessation of bleeding Prevent coagulation cascade Repair damage to a blood vessel
Prevent formation of a blood clot This client has an increased risk for DVT and PE related to the major abdominal surgery. Enoxaparin is given subcutaneously prophylactically to help prevent the formation of a thrombus or blood clot. A thrombus refers to the formation of a blood clot, sometimes from damage, in a vessel that impedes blood flow. Cessation of bleeding refers to hemostasis. The coagulation cascade is the series of events that occur in the formation of a blood clot to stop bleeding. Hemostasis and the coagulation cascade are normal processes in the body.
A client exhibits signs and symptoms of heparin overdose. The nurse would anticipate administering: Vitamin K Urokinase Protamine sulfate Drotrecogin alfa
Protamine sulfate Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin overdose. Urokinase is a thrombolytic. Drotrecogin alfa is a C-reactive protein that has anticoagulant effects.
A client accidentally ingested extra doses of warfarin at home and now presents with an elevated INR and bleeding. Which medication will the nurse prepare as prescribed to administer along with vitamin K? tranexamic acid prothrombin complex concentrate aminocaproic acid idarucizumab
Prothrombin complex concentrate. Urgent reversal of warfarin overdosage in adults with acute major bleeding can be accomplished with prothrombin complex concentrate (PCC). The drug should be administered as prescribed and concurrently with vitamin K to maintain factor levels once the effects of PCC have diminished.
A client is to receive enoxaparin. The nurse would administer this drug by which route? Intramuscular injection Subcutaneous injection Orally Intravenous infusion
Subcutaneous injection Enoxaparin (Lovenox) is administered via subcutaneous injection. Intramuscular (IM) administration is avoided because of the possibility of the development of local irritation, pain, or hematoma (a collection of blood in the tissue). Intravenous infusions are used with several anticoagulants such as heparin. Warfarin is given orally.
A client is being sent home with subcutaneous heparin after a total hip replacement. The nurse understands what symptom would indicate a serious drug reaction? Tarry stools Stomach pain Hypotension Headache
Tarry stools Tarry stools would be an indication of gastrointestinal bleeds. The most common adverse effect of heparin is bleeding.
A stable daily dose of warfarin is reached when which parameter is achieved? The INR is between 4 and 5. The INR is between 1 and 2, and the dose does not cause bleeding. The PTT is within the therapeutic range. The PT and INR are within their therapeutic ranges, and the dose does not cause bleeding.
The PT and INR are within their therapeutic ranges, and the dose does not cause bleeding. When warfarin is started, PT and INR should be assessed daily until a stable daily dose is reached (the dose that maintains PT and INR within therapeutic ranges and does not cause bleeding).
The nurse is teaching a young female about the prescribed anticoagulant. The nurse determines the session is successful when the client correctly indicates they will apply which recommendation? Take the drug on an empty stomach. Avoid caffeinated drinks. Take the drug with a glass of milk. Use a reliable contraceptive.
Use a reliable contraceptive. The nurse should instruct the female client to use a reliable contraceptive to prevent pregnancy. The nurse need not instruct the client to avoid caffeinated drinks, take the drug on an empty stomach, or take the drug with a glass of milk.
A client is receiving antihemophilic factor. The nurse understands that this drug is which factor? X VIIa VIII IX
VIII Antihemophilic factor is factor VIII, which is the factor missing in classic hemophilia. Coagulation factors VIIa and IX are separate clotting factors. Factor IX complex contains plasma fractions of many of the clotting factors and increases blood levels of factors II, VII, IX, and X.
The nurse is caring for a 73-year-old client receiving warfarin. When the nurse performs the initial shift assessment, the nurse observes blood in the client's urinary drainage bag. After reporting the observation to the physician, which substance will the nurse likely administer? Vitamin K Protamine sulfate Aminocaproic acid Platelets
Vitamin K Genitourinary bleeding is an adverse effect of warfarin. Vitamin K, a hemostatic agent that controls bleeding caused by warfarin overdose, will likely be administered to this patient.
The nurse discovers a client receiving warfarin is bleeding. What drug should the nurse prepare to administer to this client? vitamin K vitamin E calcium gluconate protamine sulfate
Vitamin K Injectable vitamin K is used to reverse the effects of warfarin. Protamine sulfate is used to reverse the effects of heparin. Vitamin E reduces effects of warfarin but is not used for that purpose. Calcium gluconate would not be indicated for this client.
A client who has been treated with warfarin after cardiac surgery is found to have an INR of 9.0. Which medication will be administered to assist in the development of clotting factors? Acetylsalicylic acid (aspirin) Vitamin E Protamine sulfate Vitamin K
Vitamin K Vitamin K is the antidote for warfarin overdosage. In this case, the client may be at the therapeutic level to control thrombus formation, but, due to the injury, it is important to control bleeding. Vitamin E is not used as an antidote for warfarin overdosage. Protamine sulfate is used as an antidote to heparin or low-molecular-weight heparin. Acetylsalicylic acid (aspirin) is used to decrease coagulation as a preventive measure for myocardial infarction.
A client who has been treated with warfarin after cardiac surgery is found to have an INR of 9.0. Which medication will be administered to assist in the development of clotting factors? Vitamin K Vitamin E Protamine sulfate Acetylsalicylic acid (aspirin)
Vitamin K Vitamin K is the antidote for warfarin overdosage. In this case, the client may be at the therapeutic level to control thrombus formation, but, due to the injury, it is important to control bleeding. Vitamin E is not used as an antidote for warfarin overdosage. Protamine sulfate is used as an antidote to heparin or low-molecular-weight heparin. Acetylsalicylic acid (aspirin) is used to decrease coagulation as a preventive measure for myocardial infarction.
A client has been prescribed intravenous heparin. What laboratory value will the nurse prioritize when providing care for this client? D-dimer factor XIII levels aPTT platelet count
aPTT Prescribers use the activated partial thromboplastin time (aPTT), which is sensitive to changes in blood clotting factors, except factor VII, to regulate heparin dosage. d-dimer test is used to help rule out deep vein thrombosis (DVT) and pulmonary embolism (PE). A platelet count measures how many platelets are present in the blood. Platelets are parts of the blood that help the blood clot. Factor XIII levels are assessed when diagnosing/managing hemophilia A.
A client with acute coronary syndrome is prescribed clopidogrel. Which additional medication will the nurse expect to be prescribed for this client? ibuprofen acetaminophen digoxin aspirin
aspirin Clopidogrel is an adenosine diphosphate receptor antagonist used to prevent platelet aggregation. In acute coronary syndrome, clopidogrel is given with aspirin to prevent thrombus formation. Clopidogrel does not need to be given with digoxin, ibuprofen, or acetaminophen.
The client is prescribed warfarin. His INR is 5.2. At what level is this dose? Within prescribed limits Subtherapeutic Elevated Therapeutic
elevated Warfarin dosage is regulated according to the INR (derived from the prothrombin [PT] time), for which a therapeutic value is between 2.0 to 3.0 in most conditions. A therapeutic PT value is approximately 1.5 times the control, or 18 seconds.
A postsurgical client possesses numerous risk factors for venous thromboembolism, including a previous deep vein thrombosis. What drug would the nurse anticipate administering while this client recovers in the hospital? cilostazol clopidogrel vitamin K heparin
heparin Heparin is frequently used to prevent postsurgical venous thromboembolism. Antiplatelet drugs do not have this indication, and vitamin K would increase the client's risks.
