NSG 210 Clotting
A patient receives a prescription for 60 mg enoxaparin. Which injection site should the nurse use to administer the medication safely? a. abdomen b. thigh c. deltoid d. flank
A Enoxaparin is a low-molecular-weight heparin that is given as a subcutaneous injection. The preferred injection sites for this medication are the right and left anterolateral abdominal wall. All subcutaneous injections should be given away from scars, lesions, or moles. The thigh and flank are not appropriate sites for administering enoxaparin because of poorer absorption of the medication in the thigh or flank, and it should not be given intramuscularly in the deltoid because of risk of hematoma development.
A 28-year-old female patient inquires about options for contraception. The nurse recognizes that if the patient takes an estrogen-based oral contraceptive, her risk for venous thromboembolism (VTE) doubles based on what statement that is made by the patient? a. "I smoke 1 ½ packs of cigarettes a day." b. "I have a job as a waitress." c. "I like to sit in my hot tub in the evenings." d. "It's been three years since my last child was born."
A Women of childbearing age who take estrogen-based oral contraceptives or postmenopausal women on oral hormone therapy (HT) are at increased risk for VTE. Women who use oral contraceptives and tobacco double their risk. Smoking causes hypercoagulability by increasing plasma fibrinogen and homocysteine levels and activating the intrinsic coagulation pathway. Occupations in which a patient is mobile, hot tub use, and previous childbirth do not indicate increased risk of VTE.
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.
ANS: B Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.
The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.
ANS: B IM injections are avoided in patients receiving anticoagulation. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.
ANS: B. The patient is difficult to arouse. Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
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 venipuncture e. applying manual pressure for at least 10 minutes on venipuncture sites e.
A, B, E 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 ten 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.
The nurse provides postoperative care for a patient and should monitor the patient for what indications of DVT? 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 Clinical findings for DVT 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 is caring for a hospitalized patient that 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 venipuncture d. avoid manual pressure at venipuncture sites e. humidify oxygen source if supplemental oxygen therapy is prescribed
A, C, E 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.
A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't seem to ever get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."
ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).
Which characteristics are related to an acute hemolytic transfusion reaction (select all that apply)? a. ABO incompatibility b. Hypothermia common c. Destruction of donor RBCs d. Acute kidney injury occurs e. Hypocalcemia and hyperkalemia f. Epinephrine used for severe reaction
ANS: A, C, D. a. ABO incompatibility c. Destruction of donor RBCs d. Acute kidney injury occurs ABO incompatibility, destruction of donor RBCs, and acute kidney injury may occur in an acute hemolytic transfusion reaction. Hypothermia, hypocalcemia, and hyperkalemia are most likely to occur in massive blood transfusion reactions. Epinephrine may be used for severe allergic transfusion reactions and the infusion may be restarted after treatment with antihistamines in mild cases
Which statements accurately describe thrombocytopenia (select all that apply)? a. Patients with platelet deficiencies can have internal or external hemorrhage. b. The most common acquired thrombocytopenia is thrombotic thrombocytopenic purpura (TTP). c. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. d. TTP is characterized by decreased platelets, decreased RBCs, and enhanced aggregation of platelets. e. A classic clinical manifestation of thrombocytopenia that the nurse would expect to find on physical examination of the patient is ecchymosis.
ANS: A, C, D. a. Patients with platelet deficiencies can have internal or external hemorrhage. c. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. d. TTP is characterized by decreased platelets, decreased RBCs, and enhanced aggregation of platelets. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. Thrombotic thrombocytopenic purpura (TTP) has decreased platelets and RBCs with enhanced agglutination of the platelets. Platelet deficiencies lead to superficial site bleeding. ITP is the most common acquired thrombocytopenia. Petechiae, not ecchymosis, is a common manifestation of thrombocytopenia.
Which type of transfusion reaction occurs with leukocyte or plasma protein incompatibility and may be avoided with leukocyte reduction filters? a. Febrile reaction b. Allergic reaction c. Acute hemolytic reaction d. Massive blood transfusion reaction
ANS: A. Febrile reaction Febrile nonhemolytic reaction is the most common transfusion reaction. Allergic reactions occur with sensitivity to foreign plasma proteins and can be treated prophylactically with antihistamines. Acute hemolytic reactions are related to the infusion of ABO-incompatible blood or components with 10 mL or more of RBCs. Massive blood transfusion reactions occur when patients receive more RBCs or blood than the total blood volume.
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/uL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
ANS: A. Platelet count is 42,000/uL. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take Coumadin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin any new medications."
ANS: B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.
ANS: B UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).
Delegation Decision: While administering an infusion of packed RBCs, which actions can the RN delegate to unlicensed assistive personnel (UAP) (select all that apply)? a. Verify that the IV is patent. b. Obtain the blood products from the blood bank. c. Obtain vital signs before and after the first 15 minutes. d. Monitor the blood transfusion rate and adjust as needed. e. Assist the RN with checking patient identification and blood product identification data.
ANS: B, C. b. Obtain the blood products from the blood bank. c. Obtain vital signs before and after the first 15 minutes. All other actions are the responsibility of the RN. The licensed practical nurse may be able to assist with the ID checks (depending on the state and the facility policy).
A patient with thrombocytopenia with active bleeding is to receive two units of platelets. To administer the platelets, what should the nurse do? a. Check for ABO compatibility. b. Agitate the bag periodically during the transfusion. c. Take vital signs every 15 minutes during the procedure. d. Refrigerate the second unit until the first unit has transfused.
ANS: B. Agitate the bag periodically during the transfusion. Because platelets adhere to the plastic bags, the bag should be gently agitated throughout the transfusion. Platelets do not have A, B, or Rh antibodies and ABO compatibility is not a consideration. Baseline vital signs should be taken before the transfusion is started and the nurse should stay with the patient during the first 15 minutes. Platelets are stored at room temperature and should not be refrigerated.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.
ANS: B. Avoid intramuscular (IM) injections. IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
A patient has a platelet count of 50,000/μL and is diagnosed with ITP. What does the nurse anticipate that initial treatment will include? a. Splenectomy b. Corticosteroids c. Administration of platelets d. Immunosuppressive therapy
ANS: B. Corticosteroids Corticosteroids are used in initial treatment of ITP because they suppress the phagocytic response of splenic macrophages, decreasing platelet destruction. They also depress autoimmune antibody formation and reduce capillary fragility and bleeding time. All of the other therapies may be used but only in patients who are unresponsive to corticosteroid therapy.
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).
ANS: B. Discontinue the heparin infusion. All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a. Apply heat to the knee. b. Immobilize the knee joint. c. Assist the patient with light weight bearing. d. Perform passive range of motion to the knee.
ANS: B. Immobilize the knee joint. The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.
ANS: B. Obtain the temperature, blood pressure, and pulse before the transfusion. UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums
ANS: B. Tarry stools Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.
A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.
ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for the patient who had just had sclerotherapy.
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a. "Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."
ANS: C Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Furthermore, anticoagulants should not be described as blood thinners.
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4° F (38° C)
ANS: C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.
ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of medication. The other actions by the nurse are appropriate.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Give the PRN diphenhydramine . b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.
ANS: C. Administer PRN acetaminophen (Tylenol). The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/L
ANS: C. Calf swelling and pain The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Following a splenectomy for the treatment of ITP, the nurse would expect the patient's laboratory test results to reveal which of the following? a. Decreased RBCs b. Decreased WBCs c. Increased platelets d. Increased immunoglobulins
ANS: C. Increased platelets Splenectomy may be indicated for treatment for ITP and when the spleen is removed, platelet counts increase significantly in most patients. In any of the disorders in which the spleen removes excessive blood cells, splenectomy will most often increase peripheral RBC, WBC, and platelet counts.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
ANS: C. Infuse normal saline 500 mL over 30 minutes. The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.
Priority Decision: A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which action is most important for the nurse to implement? a. Taking the temperature every 4 hours to assess for fever b. Maintaining the patient on strict bed rest to prevent injury c. Monitoring the patient for headaches, vertigo, or confusion d. Removing the oral crusting and scabs with a soft brush four times a day
ANS: C. Monitoring the patient for headaches, vertigo, or confusion The major complication of thrombocytopenia is hemorrhage and it may occur in any area of the body. Cerebral hemorrhage may be fatal and evaluation of mental status for central nervous system (CNS) alterations to identify CNS bleeding is very important. Fever is not a common finding in thrombocytopenia. Protection from injury to prevent bleeding is an important nursing intervention but strict bed rest is not indicated. Oral care is performed very gently with minimum friction and soft swabs.
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.
ANS: C. Notify the health care provider. The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.
ANS: C. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.
A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Check for presence of lipodermatosclerosis.
ANS: D Clinical signs of post-thrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease.
A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.
ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).
A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.
ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.
ANS: D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time
ANS: D. Activated partial thromboplastin time Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. Administer oxygen therapy at a high flow rate. b. Obtain a urine specimen to send to the laboratory. c. Notify the health care provider about the symptoms. d. Disconnect the transfusion and infuse normal saline.
ANS: D. Disconnect the transfusion and infuse normal saline. The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
The nurse reviews the medication profile of a patient and identifies that which type of medication predisposes the patient to thrombus formation? a. antibiotics b. corticosteroids c. beta-adrenergic blockers d. NSAIDs
B Corticosteroids can inhibit the fibrinolytic activity of the blood and increase the risk of thrombus formation. Antibiotics do not inhibit the fibrinolytic activity of the blood. β-adrenergic blockers are used to treat aortic dissection; side effects include dizziness, depression, fatigue, and erectile dysfunction. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation and may cause gastric bleeding.
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 administering.
B Enoxaprin is a LMWH. The nurse should not expel the air bubble from the 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 sit at a 30-degree angle for administration.
The nurse assesses that the patient with which of the following conditions is at greatest risk for venous stasis? a. diabetes mellitus b. spinal cord injury c. glaucoma d. hyperhomocysteinemia
B Venous stasis occurs because of reduced action of the muscles in the extremities and the functional inadequacy of venous valves. A spinal cord injury causes muscle inactivity and prolonged immobilization, which can lead to venous stasis.
A postoperative patient asks the nurse why daily enoxaparin has been prescribed. How should the nurse respond? A. "It will help prevent breathing problems after surgery, such as pneumonia." B. "It will help lower your blood pressure to a safe level, which is very important after surgery." C. "It will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D. "It is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
C Enoxaparin is an anticoagulant that is used to prevent deep vein thromboses (DVTs) postoperatively. Enoxaparin does not prevent breathing problems or pneumonia. Enoxaparin does not have hypotensive effects. Enoxaparin is not a medication used to treat pain.
A postoperative patient is receiving heparin. The nurse identifies that the medication is not being effective when what assessment finding is noted? a. generalized weakness and fatigue b. crackles to bilateral lung bases c. pain and swelling of lower extremity d. abdominal pain with decreased bowel sounds
C Heparin is 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. Generalized weakness, fatigue, abdominal pain, and crackles in the bases of the lungs would not necessitate the use of enoxaparin.
The nurse is preparing to administer a scheduled dose of enoxaparin 30 mg subcutaneously. What technique should the nurse use when administering the medication? A. remove the air bubble from the prefilled syringe. B. aspirate before injecting to prevent IV administration C. massage the injection site to promote absorption D. hold the skinfold during the injection but release before removing the needle
D The nurse should gather together or "bunch up" the skin between the thumb and the forefinger during the injection but should release it before removing the needle. The nurse should not remove the air bubble in the prefilled syringe, aspirate, or rub the site after injection. Topics
The nurse reviews a patient's laboratory results before administering a prescribed dose of vitamin K 1. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is at which level? a. 1.0 b. 1.2 c. 1.6 d. 2.1
D Phytonadione is the antidote to sodium warfarin (Coumadin), which the patient had been taking before admission. Warfarin is an anticoagulant that impairs the ability of the blood to clot. It is necessary to give phytonadione before surgery to reduce the risk of hemorrhage. The greatest value of the INR indicates the greatest impairment of clotting ability, making 2.1 the correct selection. Values of 1.0, 1.2, and 1.6 indicate lower INR results, which may not require vitamin K 1.
A patient reports pain and itchiness in a lower extremity. Upon further assessment, a nurse observes that the extremity is reddened and warm. The patient's body temperature is 101° F. What complication does the nurse suspect? a. aortic aneurysm b. deep vein thrombosis c. disseminated intravascular coagulation d. superficial vein thrombosis
D The presence of an itchy, reddened, painful, and warm lower extremity characterizes a superficial vein thrombosis. A patient with superficial vein thrombosis may also have an elevated body temperature. Altered bowel elimination, abdominal and chest pain are symptoms of an aortic aneurysm. Bluish fingers and toes, pallor, rubor, throbbing, and aching pain due to exposure to cold are symptoms of Raynaud's phenomenon. Atherosclerosis, arterial stenosis, and decreased Doppler pressures are symptoms of peripheral artery disease.
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
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.
Priority Decision: The nurse is preparing to administer a blood transfusion. Number the actions in order of priority (1 is first priority action; 10 is last priority action). a. Verify the order for the transfusion. b. Ensure that the patient has a patent 18-gauge IV. c. Prime the transfusion tubing and filter with normal saline. d. Verify that the physician has discussed risks, benefits, and alternatives with the patient. e. Obtain the blood product from the blood bank. f. Ask another licensed person (nurse or MD) to assist in verifying the product identification and the patient identification. g. Document outcomes in the patient record. Document vital signs, names of personnel, and starting and ending times. h. Adjust the infusion rate and continue to monitor the patient every 30 minutes for up to an hour after the product is infused. i. Infuse the first 50mL over 15 minutes, staying with the patient. j. Obtain the patient's vital signs before starting the transfusion.
a. 1 b. 3 c. 4 d. 2 e. 5 f. 6 g. 10 h. 9 i. 8 j. 7.
Number in sequence the events that occur in disseminated intravascular coagulation (DIC). a. Activation of fibrinolytic system b. Uncompensated hemorrhage c. Widespread fibrin and platelet deposition in capillaries and arterioles d. Release of fibrin-split products e. Fibrinogen converted to fibrin f. Inhibition of normal blood clotting g. Production of intravascular thrombin h. Depletion of platelets and coagulation factors
a. 5 b. 8 c. 3 d. 6 e. 2 f. 7 g. 1 h. 4