PrepUclotting Exam 4
Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?
Phlebitis
A client is 24 hours postpartum. The nurse anticipates that the client's body is returning to homeostasis. Which assessment finding requires immediate intervention?
Positive Homans' sign
A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, (600ml blood loss)which postpartum complication has the client developed?
Postpartum hemorrhage.
Which goal is most important when developing a long-term care plan for a child with hemophilia?
Prevent injury during each stage of development.
The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a patient?
Prior to surgery
A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care the nurse notes the wound base is beefy red and bleeds easily during wound cleansing. Which of the following stages of wound healing should the nurse recognize with this client's wound?
Proliferation Phase
A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device?
Promotes circulation of venous blood
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate
Which of the following medications is an antidote to heparin
Protamine sulfate
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?
Prothrombin time (PT)
A client has had oral anticoagulation ordered. What should you monitor for when your client is taking oral anticoagulation?
Prothrombin time (PT) or international normalized ratio (INR)
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?
Recent pelvic surgery
A DIABETIC client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied?
Remove elastic stockings once per day and observe lower extremities.
A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do?
Return to laboratory for analysis of prothrombin times.
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin.
Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery?
Stockings
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following?
Tense and relax muscles in lower extremities.
The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?
The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?
The client will be immobile during and shortly after surgery.
A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?
The client with unilateral leg swelling who's complaining of anxiety and shortness of breath
A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?
The client's right lower leg is red, swollen, and warm to touch.
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first
assess the oxygen saturation
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?
coumadin
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to:
lose weight by following a reduced calorie, balanced diet.
The nurse is orienting a new graduate nurse applying graduated compression stockings to the client. The nurse should intervene immediately when the new graduate nurse:
massages the client?s legs during the morning care.
A 45-year-old male client with a confirmed DVT is being discharged from the ED. Which of the following client statements indicates that the client has received proper nursing instruction and understands how to manage his condition?
"I need to do my leg exercises five times or more every hour."
The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching
"I should avoid constipation to decrease chances of bleeding."
A client is prescribed heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin would the nurse administer? Record your answer using one decimal place. (For example: 6.2)
0.6
A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma.
1, 2, 3, 4, 5
Heparin therapy is usually considered therapeutic when the patient's activated partial thromboplastin time (aPTT) is how many times normal?
2 to 2.5
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?
Petechiae
The nurse notes that a patient has round red macules over the lower extremities. The nurse documents this finding as which of the following?
Petechiae
A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?
A bleeding disorder
A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
6 hours
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
Notify the health care provider (HCP).
Which of the following patients most likely requires special preoperative assessment and treatment as a result of his or her existing medication regimen?
A woman who takes daily anticoagulants to treat atrial fibrillation
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe for blood in stool
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe stools for blood.
Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy?
APTT
A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, it is important for the nurse to
Administer the prescribed enoxaparin (Lovenox).
Which of the following medication classifications should be avoided in the treatment of brain tumors?
Anticoagulants
A patient has been diagnosed with hyphema. Which of the following medication classifications stabilizes clot formation at the site of hemorrhage?
Antifibrinolytics
Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery?
Applying antiembolism stockings
Which of the following nursing interventions should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a patient with leukemia?
Applying prolonged pressure to needle sites or other sources of external bleeding
A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol abuse. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next
Ask the client if she has noted any blood in her stools lately.
A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol abuse. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next?
Ask the client if she has noted any blood in her stools lately.
If warfarin is contraindicated as a treatment for stroke, which of the following medication is the best option?
Aspirin
A patient with AML has pale mucous membranes and bruises on his legs. What is the primary nursing intervention?
Assess the patient's hemoglobin and platelets.
Which of the following groups of patients are at risk for thrombophlebitis?
Older adults
Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy?
aspirin
A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse?
Call the physician to report the finding.
A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?
Check fundus for position and consistency
A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings does the nurse find most concerning?
Chest pain and dyspnea
Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin?
Clopidogrel (Plavix)
A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to?
Coagulopathy
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do?
Perform ankle pumps and foot range-of-motion exercises.
Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first?
Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings.
The most common cause of iron-deficiency anemia in premenopausal women includes which of the following?
Menorrhagia
A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply.
Decreased white blood cells Decreased RBCs Decreased platelets
The nurse is caring for a client following cardiac valve replacement. Which nursing action is correct when obtaining a Homan's sign to screen for thrombophlebitis?
Dorsiflexion of the foot noting calf pain
While caring for a the postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thromobosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibited which symptom?
Dyspnea
A patient who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action?
Evaluate the patient's platelet count.
A nurse is caring for a patient who has a PICC line. Which nursing action is recommended?
Flush using normal saline and/or heparin solution according to facility policy.
A patient is taking ginkgo biloba, a botanical supplement. She asks the nurse if it would be safe to take aspirin for her arthritis at the same time. The nurse's response is based on what knowledge?
Ginkgo biloba affects platelet function and should not be taken with aspirin.
The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. The nurse teaches the parents
How to administer factor VIII intravenously at the first sign of bleeding
A nurse receives an order to apply antiembolism stockings for a patient at risk for deep vein thrombosis. Which of the following is an accurate guideline for applying these stockings?
If the patient was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.
Which of the following is true regarding hormonal contraception?
Increased risk for venous thromboembolism
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first
Initiate O2
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
The client teaching instructions for a 57-year-old male client with thrombophlebitis who is being discharged should include which of the following? Select all that apply
Perform leg exercises each hour. Ambulate as tolerated. Avoid sitting for too long.
When providing client teaching about continuous bladder irrigation following prostate surgery, the nurse should tell the client:
The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder."
Petechiae are associated with which of the following disorders?
Thrombocytopenia
Which of the following is the most common complication of prosthetic valves?
Thromboembolism
The nurse is working in an internal medicine office. A daughter brings her elderly mother to the doctor's appointment. Upon reviewing the medication list, the daughter states, "Which medication is prescribed to prevent a stroke?" The nurse is correct to answer which medication?
Ticlopidine
The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery?
Vitamin K
Which nutrient plays an important role in normal blood clotting?
Vitamin K
Which of the following medications is the antidote to Coumadin?
Vitamin K
The nurse understands that which of the following medications will be administered for 6 to 12 weeks following prosthetic porcine valve surgery?
Warfarin
A young male client is diagnosed with a mild form of hemophilia. He is experiencing bleeding in the joints with pain. In preparing the client for discharge, the nurse educates the client to
Wear a medical identification bracelet.
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is
a contrast phlebography.
Bright red bleeding following prostate surgery indicates which of the following?
arterial
The most common cause of iron deficiency anemia in men and postmenopausal women is
bleeding.
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
blood pressure
A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?
depot medroxyprogesterone acetate injection
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to:
dissolve clots
What is the expected outcome of thrombolytic drug therapy for stroke?
dissolve emboli
The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first:
don gloves and apply direct pressure over the site.
The nurse is caring for a client following cardiac valve replacement. Which nursing action is correct when obtaining a Homan's sign to screen for thrombophlebitis?
dorsiflextion of the foot noting pain
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by
forcing blood into the deep venous system
A recently extubated client has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP?
hemoglobin and hematocrit
Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant?
hemoglobin level, hematocrit, and platelet count
Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
hemorrhagic skin rash
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms?
hypertension
A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest
thrombophlebitis
A woman who gave birth to a healthy baby 6 hours is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. The nurse should:
notify the health care provider (HCP).
The results of which serologic test should the nurse have on the medical record before a client is started on tissue plasminogen activator or alteplase recombinant?
partial thromboplastin time
A female client is receiving chemotherapy and is experiencing pancytopenia. Which laboratory result most warrants that the nurse immediately contact the health care provider (HCP)?
platelet count of 12,000/mm3
A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings?
platelet count of 80 x 103/mm3 (80 X 109/L)
The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of
thrombophlebitis
Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for:
thrombophlebitis.
Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug
prevent further blood clot formation
Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy?
prothrombin time (PT)
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:
revascularize the blocked coronary artery.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward
Two weeks before a client is scheduled for an ileostomy, the nurse should instruct the client to:
stop taking drugs that will interfere with clotting (aspirin, ibuprofen).
A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?
tachycardia
A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of:
thrombocytopenia.
A 20-year-old client visiting the clinic requests the use of oral contraceptives. When reviewing the client's history, which finding would alert the nurse to a possible contraindication to using these agents?
thrombophlebitis
A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used:
to provide long-term access to central veins.
The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)?
urinary output of 25 mL in the past hour