Lewis Chap. 37 Venous

The nurse provides postoperative care for a patient and should monitor the patient for what indications of venous thromboembolism (VTE)? Select all that apply. A. Venous distention B. Vein appears as a palpable cord C. Deep-reddish color over the affected area D. Itchiness and warmth over the affected area E. Tenderness with palpation Eugene off target

A c e, Rationale Clinical findings for VTE include tenderness to pressure over involved vein, induration of overlying muscle, venous distention, edema, possible mild to moderate pain, and a deep reddish color to area caused by venous congestion. Itchiness and cordlike texture are characteristics of superficial venous thrombosis.

A patient admitted to the health care facility with venous thromboembolism (VTE) is prescribed unfractionated heparin, to be administered subcutaneously. What technique should the nurse use when administering the medication? Select all that apply. A. Inject deep into abdominal fatty tissue. B. Hold skinfold during injection. C. Release skinfold after removing needle. D. Avoid aspiration. E. Rub site after injection.

A, b, d Rationale When administering unfractionated heparin subcutaneously, the nurse should inject deep into the abdominal fatty tissue, hold the skinfold during injection but release before removing the needle, and avoid aspiration. The nurse should not inject intramuscularly, rub the site after injection, or aspirate.

A patient is prescribed warfarin following a deep venous thrombosis and pulmonary embolism. What information should the nurse include in the teaching plan? Select all that apply. A. Eliminate green vegetables from the diet. B. Use a soft toothbrush and observe the gums for bleeding. C. Wear a bracelet that identifies the patient is taking an anticoagulant. D. Blood coagulation testing is needed only for the first 4 to 6 weeks of therapy. E. Do not take ibuprofen (Motrin) or aspirin unless prescribed by the primary health care provider.

B c e Rationale Warfarin acts as an anticoagulant by inhibiting liver production of vitamin K. Patients are at risk for bleeding and should use a soft toothbrush. Wearing an identification bracelet will alert emergency medical personnel in case the patient is unable to inform them about the medication. Nonsteroidal antiinflammatory medications, including aspirin, potentiate the anticoagulation effect and may cause problems with bleeding. Green vegetables, which are sources of vitamin K, should be taken in consistent amounts but need not be eliminated. The patient taking warfarin will continue to need coagulation laboratory testing (Protime/internationalized normal ratio [INR]) while taking the medication because the anticoagulant effect is influenced by many factors, including medications and diet.

It is appropriate for the registered nurse (RN) to delegate which intervention to a licensed practical nurse (LPN) when providing care to a patient with venous thromboembolism? A. Monitoring for adverse effects of anticoagulant use B. Administering prescribed subcutaneous anticoagulants C. Providing instructions about the use of pressure to stop bleeding D. Teaching about the use of compression stockings during a hospital discharge

B. Rationale The LPN can administer prescribed subcutaneous anticoagulants to the patient because it is within his or her scope of profession. The RN, not the LPN, should monitor for adverse effects of anticoagulant use, provide instructions to the patient about the use of pressure to stop bleeding, and teach the patient about the use of elastic compression stockings during a hospital discharge.

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? A. "This medication will help prevent breathing problems after surgery, such as pneumonia." B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.

The nurse is caring for a patient with superficial vein thrombosis and expects what assessment findings? A. Tenderness to pressure over the involved vein B. Presence of edema with pain C. Induration of the overlying muscle D. Appearance of the vein as a palpable cord

D. Rationale In superficial vein thrombosis, the vein appears as a palpable cord. Tenderness to palpation over the involved vein, presence of edema with pain, and induration of overlying muscle are noted in venous thromboembolism. Edema rarely occurs in superficial vein thrombosis.

A patient has a 2-month history of taking warfarin as treatment for deep vein thrombosis (DVT). The patient is scheduled for an unrelated surgery. The nurse determines that it is safe and necessary to give vitamin K based on what international normalized ratio (INR) result? A. 1.0 B. 1.2 C. 2.0 D. 3.4

D. Rationale Vitamin K is the antidote to warfarin. Warfarin is an anticoagulant that impairs the ability of the blood to clot; therefore, it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The value of the INR indicates an impairment of clotting ability, making 3.4 the correct selection. For a patient with a history of VTE, a therapeutic INR is maintained between 2.0 and 3.0.

What interventions will decrease the likelihood of a patient developing varicose veins? Select all that apply. A. Maintaining ideal body weight B. Avoiding long periods of sitting C. Taking 325 mg of aspirin daily D. Applying hydrating lotions to the skin of legs daily E. Avoiding standing for long periods

Rationale A, b, e Varicose veins are dilated, tortuous veins that occur mainly in the legs. Family history is thought to be a factor in the development of incompetent valves in the leg veins that become varicose veins. Strategies that promote competent veins in the legs include walking, avoiding standing and sitting for long periods of time, and keeping an ideal body weight. Aspirin therapy will not prevent varicose veins. Hydrating lotions will condition the skin but not prevent varicose veins. If

A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? A) Keep the patient on bed rest. B) Assist the patient with walking several times. C) Have the patient sit in the chair several times. D) Place the patient on her side with knees flexed.

B) To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? A. "Try to keep your stockings on 24 hours a day, as much as possible." B. "While you're still lying in bed in the morning, put on your stockings." C. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." D. "Your stockings will be most effective if you can remove them for a few minutes several times a day."

B. "While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

The nurse is preparing to administer enoxaparin subcutaneously to a patient with vascular insufficiency. What technique should the nurse use when administering the medication? A. Spread the skin before inserting the needle. B. Leave the air bubble in the prefilled syringe. C. Use the back of the arm as the preferred site. D. Sit the patient at a 30-degree angle before administration.

B. The nurse should not expel the air bubble from a prefilled syringe because it should be injected to clear the needle of medication and to avoid leaving medication in the needle track in the tissue. The skin is not spread before inserting the needle. The abdomen is the preferred site of administration. The patient does not need to sit at a 30° angle for administration

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? A. Generalized weakness and fatigue B. Crackles bilaterally in the lung bases C. Pain and swelling in lower extremity D. Abdominal pain with decreased bowel sounds

C. Pain and swelling in lower extremity Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? A. Hematocrit (Hct) B. Hemoglobin (Hgb) C. Prothrombin time (PT) D. Partial thromboplastin time (PTT)

C. Prothrombin time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.

The nurse is caring for a hospitalized patient who is receiving anticoagulant therapy for venous thromboembolism (VTE). Which interventions should the nurse perform for this patient? Select all that apply. A. Monitor platelet count. B. Use restraints as needed. C. Use small-gauge needle for venipunctures. D. Avoid manual pressure at venipuncture sites. E. Humidify O 2 source if supplemental O 2 is prescribed

A c e Rationale Nursing interventions for the patient taking anticoagulant therapy include evaluation of platelet count for signs of heparin-induced thrombocytopenia. The nurse should preferably use a small-gauge needle for venipuncture. The nurse should humidify O 2 source if supplemental O 2 is prescribed; this will decrease the risk of nosebleed. Restraints should be avoided if possible, but if they are needed, the nurse should use soft, padded restraints. Manual pressure should be applied for 10 minutes or longer at venipuncture sites.

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? A) Duplex ultrasound B) Contrast venography C) Magnetic resonance venography D) Computed tomography venography

A) The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

The nurse identifies that what interventions are appropriate to be included on the plan of care for a patient receiving anticoagulant therapy? Select all that apply. A. Checking the platelet count B. Administering stool softeners C. Utilizing the intramuscular route for medication administration D. Using large-gauge needles for venipunctures E. Applying manual pressure for at least 10 minutes on venipuncture sites

A, B, e Rationale The nurse should check the platelet count because anticoagulant therapy may induce thrombocytopenia. Stool softeners prevent hard stools, which reduces straining and the risk of bleeding. The nurse should apply manual pressure for at least 10 minutes on the venipuncture site to prevent bleeding. The nurse should avoid administering an intramuscular injection to the patient to prevent a hematoma formation. The nurse should use small-gauge needles for venipunctures to prevent bleeding.

A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? A. Low-fat diet B. High-protein diet C. Calorie-restricted diet D. High-carbohydrate diet

B. High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? A. Platelet count B. Activated clotting time (ACT) C. International normalized ratio (INR) D. Activated partial thromboplastin time (APTT)

D. Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin, but that is not the expected effect.

The nurse is examining a female patient who experiences leg edema and pain. What history findings indicate that the patient is at a high risk for venous thromboembolism (VTE)? Select all that apply. A. The patient uses tobacco. B. The patient takes an estrogen-based oral contraceptive. C. The patient has been taking aspirin daily for 1 year. D. The patient has a family history of VTE. E. The patient lives in a high-altitude area.

A. B. D. E. Rationale A woman who uses an estrogen-based oral contraceptive and tobacco is at high risk for VTE. These compounds may cause hypercoagulability and may activate the intrinsic coagulation pathway that leads to deep vein thrombosis and pulmonary embolism. The risk increases if the patient has a family history of VTE because the patient may carry the mutated genes responsible for the disease. High altitude causes hypercoagulability of blood. Some medications, such as corticosteroids, may stimulate thrombus formation, but aspirin has shown no such tendency.

The nurse provides postoperative care for a patient and should monitor the patient for what indications of venous thromboembolism (VTE)? Select all that apply. A. Venous distention B. Vein appears as a palpable cord C. Deep-reddish color over the affected area D. Itchiness and warmth over the affected area E. Tenderness with palpation

A. C. E. Rationale Clinical findings for VTE include tenderness to pressure over involved vein, induration of overlying muscle, venous distention, edema, possible mild to moderate pain, and a deep reddish color to area caused by venous congestion. Itchiness and cordlike texture are characteristics of superficial venous thrombosis.

The nurse reviews a patient's medical record and notes long-term use of heparin. The nurse identifies that the patient is at risk for what complication? > A. \Osteoporosis B. Erectile dysfunction C. Gastrointestinal bleeding D. Venous thromboembolism

A. Rationale Long-term use of heparin decreases bone density and increases the risk of osteoporosis. Metoprolol can cause erectile dysfunction. Long-term use of aspirin causes gastrointestinal bleeding. Heparin is used to prevent venous thromboembolism.

The nurse reviews the coagulation profile results of a patient who is scheduled for surgery. The nurse concludes that the patient is stable for surgery after noting which international normalized ratio (INR) result? A. 1.0 B. 1.8 C. 2.7 D. 3.4

A. Rationale The larger the INR number, the greater the amount of anticoagulation. For this reason, a level of 1.0 indicates that it is safe to proceed with the planned surgery.

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A. Remove the patient's IV catheter. B. Apply an ice pack to the affected area. C. Decrease the IV rate to 20 to 30 mL/hr. D. Administer prophylactic anticoagulants.

A. Remove the patient's IV catheter.

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? A. Buttock, upper outer quadrant B. Abdomen, anterior-lateral aspect C. Back of the arm, 2 inches away from a mole D. Anterolateral thigh, with no scar tissue nearby

B. Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or mole

What is an appropriate nursing intervention for a patient following vein ligation surgery? A. Maintaining elastic compression stockings at all times B. Keeping the legs elevated at 15 degrees C. Reporting any bruising and discoloration D. Asking the patient to avoid deep breathing

B. Rationale After vein ligation surgery, the nurse should ensure that the patient keeps his or her legs elevated at 15 degrees to reduce edema. Elastic compression stockings should be removed every 8 hours for short periods and reapplied. Some bruising and discoloration are normal. The patient should be encouraged to breathe deeply to promote venous return.

The registered nurse observes a new graduate nurse providing postoperative instructions to a patient with a history of cardiovascular disease. Which statement made by the new graduate nurse requires correction? A. We will ambulate you in the halls four to six times a day." "B. It is important to flex and extend your hips, knees, and feet every eight hours." "C. You will need to wear an intermittent pneumatic compression device." "D. You will receive enoxaparin in your stomach twice a day until you are discharged."

B. Rationale The measures listed are to prevent postoperative venous thromboembolism. Hips, knees, and feet should be flexed at least every two to four hours while awake. The other statements indicate adequate understanding. Ambulation should take place four to six times a day. The patient should wear the compression devices at all times unless bathing, walking, or during the skin assessment. Enoxaparin will be given subcutaneously to the abdomen twice a day until the patient is discharged.

A patient with varicose veins has been prescribed compression stockings. What information should the nurse provide to the patient? "A. Try to keep your stockings on 24 hours a day, as much as possible." "B. While you're still lying in bed in the morning, put on your stockings." "C. Dangle your feet at your bedside for 5 minutes before putting on your stockings." "D. Your stockings will be most effective if you can remove them for a few minutes several times a day."

B. Rationale The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling feet at the bedside before application of stockings is likely to decrease their effectiveness. p. 826

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A. Decreased cardiac output B. Increased blood pressure C. Cerebral or pulmonary emboli D. Excessive bleeding from incision or IV sites

C. Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? A. Pulmonary embolism B. Pulmonary hypertension C. Post-thrombotic syndrome D. Venous thromboembolism

D) The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? A) 1.0 B) 1.2 C) 1.6 D) 2.2

D) Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A. Remove the air bubble in the prefilled syringe. B. Aspirate before injection to prevent IV administration. C. Rub the injection site after administration to enhance absorption. D. Pinch the skin between the thumb and forefinger before inserting the needle.

D. Pinch the skin between the thumb and forefinger before inserting the needle. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

What is the priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? A. Application of topical antibiotics to venous ulcers B. Maintaining the patient's legs in a dependent position C. Administering oral or subcutaneous anticoagulants D. Teaching the patient the correct use of compression stockings

D. Rationale CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or intravenous, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

The nurse reviews the prescribed medications taken by a patient diagnosed with thromboangiitis obliterans (Buerger's Disease). Which medication is contraindicated and should be questioned by the nurse? A. Cilostazol B. Nifedipine C. Acetaminophen D. Nicotine transdermal patch

D. Rationale Thromboangiitis obliterans (Buerger's Disease) is an inflammatory condition of small arteries and veins in the extremities that leads to tissue ischemia and ulcer development. The condition occurs mostly in young males with a history of heavy use of tobacco or marijuana. Treatment involves complete cessation of tobacco to stop the inflammation. A nicotine patch is contraindicated and should be questioned. The condition may be treated with antiplatelet medications such as cilostazol, or a calcium channel blocker agent such as nifedipine, for vasodilation effect. Acetaminophen may be used for pain relief.

The nurse understands that venous ulcers are characterized by which assessment findings? Select all that apply. A. Bluish tinge of the extremities B. Capillary refill greater than 3 seconds C. Pain worse with leg in a dependent position D. Well-defined edges along the ulcer E. Located above the medial malleolus

Rationale C. E. Venous ulcers are often quite painful. Pain may be worse when the leg is in a dependent position. Venous ulcers classically are located above the medial malleolus. A blue tinge to the skin is associated with decreased arterial oxygenation to the tissue. Venous ulcers have a bronze-brown pigmentation, and the capillary refill of the extremity is less than 3 seconds with venous disease. Well-defined edges are seen with arterial ulcers.