EAQ Clotting

A nurse is caring for a postpartum client who had abruptio placentae. Which finding indicates that disseminated intravascular coagulation (DIC) is occurring?

Bleeding at the venipuncture site

Which client is at greatest risk for the development of a venous thrombosis?

A 68-year-old male on bed rest following a left hip fracture

A client undergoes cardiac catheterization via the femoral artery. What is the most important nursing action after the procedure?

Assess the groin for bleeding

A 4-year-old child is admitted to the pediatric unit for a tonsillectomy. During preoperative planning a nurse reviews the child's laboratory report. Which lab value is of most significance in this situation?

Coagulation studies

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?

Continuous infusion of heparin

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client?

Edema of the left leg

A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?

International Normalized Ratio (INR)

When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs?

Worsening ankle edema as the day progresses.

A nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen (Advil) for discomfort associated with osteoarthritis and notifies the health care provider. Which drug does the nurse expect will most likely be prescribed instead of the Advil?

Acetaminophen (Tylenol)

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?

An activated partial thromboplastin (APTT) twice the usual value

What is the priority nursing action when caring for a client with disseminated intravascular coagulation?

Avoid giving intramuscular injections.

To prevent excessive bruising when administering subcutaneous heparin, the nurse should:

Avoid massaging the injection site after the injection

The nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of:

Erythrocytes

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life threatening response of thrombocytopenia?

Hematuria, Ecchymosis

A nurse is assessing a client who is scheduled for a liver biopsy. What assessment finding needs to be reported immediately because it warrants a postponement of the liver biopsy?

International normalized ratio (INR) of 4.0

Three days after surgery, a client complains of pain in the calf. The nurse assesses the client and suspects thrombophlebitis. The nurse's next action should be to:

Maintain bed rest and notify the primary health care provider

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy?

Melena, Purpura, Hematuria

A nurse teaches a client about warfarin (Coumadin). Which information is essential for the nurse to include in the education plan?

Periodic blood testing is necessary

A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by:

Pinching the nostrils together

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?

The mother is a carrier of the disorder but is not affected by it.

The mother of a boy with recently diagnosed hemophilia is pregnant with her second child. She asks the nurse what the chances are that her baby will also have hemophilia. How should the nurse respond?

There is a 25% chance that the baby will be affected.

An adolescent is admitted with an acute hemophilia episode. Rest, ice, compression, and elevation will be most helpful in:

Controlling bleeding and retaining joint function

A 6-year-old child who has undergone abdominal surgery complains of incisional pain. The nurse administers the prescribed acetaminophen (Tylenol). The mother asks the nurse why her child isn't being given ibuprofen (Advil). The nurse considers the pharmacokinetics of ibuprofen before responding that:

It could prolong bleeding time."

A toddler with hemophilia A is receiving factor VIII. The mother asks the nurse, "If my son hurts himself, I'll give him 2 children's Advil. Is that right?" How should the nurse respond?

'Give him Tylenol—Advil may cause bleeding."

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that:

Crosses the suture line

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?

Joints

A client had a total knee replacement several days ago and has been receiving warfarin sodium (Coumadin) therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the health care provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. The next action the nurse should take is to:

Maintain the client on bed rest until the health care provider reviews the laboratory results

A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin (Coumadin). Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation?

Presence of blood in urine

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on the list?

Spinach, Broccoli