Anticoagulation Questions

Bonus question: What does the acronym SNOT stand for?

Seven (VII), Nine (IX), One-zero (X), and Two (II) Vitamin K-induced clotting factors that are inhibited by warfarin

A patient on renal dialysis is given which of the following as an additive to prevent clotting? A. Warfarin B. Aspirin C. Heparin D. Apixiban

C. Heparin Heparin is the drug of choice for reducing the likelihood of clotting during dialysis procedures.

A nurse is reviewing the medications for her patients prior to morning med administration. Which of the following patients would the nurse discuss with the provider before administering their medication? A. Aspirin for a patient on warfarin therapy following an MI. B. Clopidogrel for a patient scheduled for a coronary artery bypass. C. Apixaban (Eliquis) for a 60-year-old with atrial fibrillation. D. Vitamin K IV for a bleeding patient on warfarin.

A. Aspirin for a patient on warfarin therapy following an MI. ASA can decouple warfarin from plasma albumin resulting in higher levels of free warfarin. This, along with ASA's anti-platelet properties can increase the risk of bleeding. The nurse would want to ensure that the aspirin is prescribed on schedule with warfarin rather than PRN.

A 55-year old presented with complaints of pain and swelling her lower right calf. She stated she returned from a trip to India two days prior. Which of the following orders should the nurse expect from the provider? A. D-dimer test, IV heparin, aPTT monitoring q4 hrs B. Bed rest, dangle legs, Vitamin K-rich diet C. Troponin tests, IV protamine sulfate D. CT scan, IV enoxeparin, INR monitoring

A. D-dimer test, IV heparin, aPTT q4 hrs The patient is likely experiencing a DVT as result of her long plane ride.

Following administration of protamine sulfate, the patient starts to experience signs of an allergic reaction. These signs include (select all that apply) A. Wheezing B. Anaphylaxis C. Hypertension D. Rash E. Cough

A, B, D

How are ADP receptor antagonists similar to aspirin? (select all that apply) A. They are antiplatelets, inhibiting the aggregation of platelets and thus clot formation. B. They function for the entire life of the platelet. C. They are used to clear clots from central lines. D. Their primary adverse reaction is bleeding.

A, B, D Antiplatelets are not thrombolytics and cannot break up currently formed clots, so they are not used to clear central lines.

An 80-year old woman started slurring her words and exhibiting a right sided facial droop. Her husband rushed her to the hospital and she was immediately transferred to the nearest stroke center 30 mins away. By the time she arrived and was evaluated, 1 hour and 15 mins had passed since she first exhibited signs of a stroke. Which of the following statements is true? A. Alteplase (tPA) can be given because it is within the 3-4.5 hour time limit from onset of symptoms. B. The patient will be sent home with a prescription for retaplase. C. An LPN will administer the IV dose of alteplase and delegate cardiac monitoring to a UAP. D. Labs and imaging confirmed a hemorrhagic stroke so the provider administered the first bolus of alteplase.

A. Alteplase (tPA) can be given because it is within the 3-4.5 hour time limit from onset of symptoms Retaplase is given via IV in emergent settings, not taken at home. A skilled clinician should administer these drugs as the side effects may be severe. Thrombolytics are contraindicated for hemorrhagic strokes.

A 78-year old has been taking edoxaban for prevention of a second ischemic stroke. She sometimes has trouble remembering to take her pill each day. She skipped her dose before breakfast yesterday. What should she do? A. Skip the missed dose and set an alarm clock to go off daily at the same time. B. Double up on her dose today. C. Take yesterday's dose then wait 4 hours and take today's dose. D. Call her provider's office to get an appointment for aPTT/INR monitoring.

A. Skip the missed dose and set an alarm clock to go off daily at the same time. It is important to take the dose at the same time each day. Setting an alarm can help ensure that the medication is taken regularly. Take the skipped dose only if it not close to time for the next dose. Do not double up on doses. Edoxaban does not require blood monitoring.

A nutritionist reminds his client to consume consistent quantities of green leafy vegetables, broccoli and Brussel sprouts each week. Which anticoagulant therapy is his client likely on? A. Warfarin B. Heparin C. Aspirin D. Enoxaparin

A. Warfarin These foods are rich in Vitamin K. Clients on warfarin (a Vit K antagonist) need to maintain consistent levels of Vit K intake so as to not interfere with dosing.

Which of the following are risk factors for developing a thrombosis? (Select all that apply) A. Atrial fibrillation B. Smoking C. Family history of clotting disorders D. Pregnancy E. Hypertension F. Hyperlipidemia

All of the above are risk factors for developing dangerous blood clots.

A nurse is reviewing discharge instructions with a patient following CABG surgery. Which statement indicates the need for more teaching? A. I will take my low dose aspirin daily for life. B. I will celebrate the success of my surgery with drinks tomorrow night with my buddies. C. I will be alert for signs of bleeding like bruising or bleeding gums. D. I will take both aspirin and clopidogrel (Plavix) to reduce my risk of a stroke or heart attack.

B. I will celebrate the success of my surgery with drinks tomorrow night with my buddies. Alcohol should be avoided in patients taking antiplatelets like ASA and clopidogrel. Clotting factors are produced in the liver and alcohol is hepatotoxic. The combined effect of alcohol and antiplatelets could increase the risk of bleeding.

Which of the following statements would require the nurse to provide further education to a patient going home on warfarin therapy? A. I will need to come in once a month for INR monitoring. B. If my dose is correct, my INR should be between 1.5 and 2.0. C. I will notify my provider if I want to get pregnant. D. This medication is not a thrombolytic and cannot break down any clots I currently have.

B. If my dose is correct, my INR should be between 1.5 and 2.0. The correct therapeutic INR should be between 2.0 and 3.0.

A patient is undergoing spinal cord surgery and is on IV heparin. He is showing signs of uncontrolled bleeding and is given protamine sulfate. What is the mechanism by which this drug works? A. Promotes platelet aggregation. B. The positively charged protein binds to negatively charged heparin C. Blocks Vitamin K-related clotting factor synthesis D. Strengthens fibrin matrix

B. The positively charged protein binds to negatively charged heparin Protamine sulfate is the antidote to heparin. Its positive charge binds to the negative charge of heparin. 1 mg of protamine sulfate can neutralize 100 units of heparin.

A patient is recovering from an MI at home and asks his son to go the pharmacy and purchase a bottle of baby aspirin. His son returns with a small bottle of 325 mg aspirin. Which of the following is NOT a possible adverse outcome of this faulty purchase? A. Neutropenia B. Tinnitus C. Embolism D. Warfarin overdose

C. Embolism Aspirin is an antiplatelet which works to prevent clotting. All of the other options are risks from aspirin toxicity caused by accidentally ingesting 325 mg instead of 81 mg daily.

A patient hospitalized with DIC is on heparin therapy. The nurse delegates oral care to an AP who reports bleeding gums following brushing with a soft bristled tooth brush. During assessment, the nurse also notes rectal bleeding. What are other signs or symptoms the nurse may expect? A. Low aPTT, elevated platelets B. Thrombocytopenia, bruising, hematuria C. Elevated hematocrit and hemoglobin D. Tachycardia and high blood pressure

B. Thrombocytopenia, bruising, hematuria The patient's dose of heparin may be too high leading to bleeding. High aPTT and low hematocrit, hemoglobin and blood pressure are all associated with bleeding risk.

Low-molecular weight heparin (LMWH) is dosed based on: A. INR B. Weight C. aPTT D. Age

B. Weight Unlike unfractionated heparin which is dosed based on aPTT, fractionated heparin is dosed based on weight and does not require blood monitoring.

What is the therapeutic aPTT range for heparin? A. 20-40 seconds B. 40-60 seconds C. 60-80 seconds D. 80-100 seconds.

C. 60-80 seconds Normal aPTT is 40 seconds and the therapeutic is 1.5 - 2 times higher than normal.

Which of the following correctly describes the purpose of anticoagulants? A. Prevent blockages by stabilizing already-formed clots. B. Break down clots to enhance blood flow. C. Inhibit steps of the clotting cascade to prevent formation and growth of clots. D. Prevent movement of clots by enhancing the effects of fibrin.

C. Inhibit steps of the clotting cascade to prevent formation and growth of clots. Anticoagulants work to prevent the formation of new clots and the growth of current clots. They work by inhibiting steps of the clotting cascade and synthesis of clotting factors.

A 72-year old with a history of atrial fibrillation was on warfarin for six years following hospitalization for a DVT. He asked his doctor to switch him to something that wouldn't require constant blood monitoring. Which drug might the provider prescribe? A. Protamine sulfate B. Ticlopidine C. Rivaroxaban D. Alteplase

C. Rivaroxaban Xarelto is an anticoagulant like warfarin, and does not require INR monitoring. Protamine sulfate is the antidote to heparin, ticlopidine is an antiplatelet, and alteplase is a thrombolytic.

Which drug has the most known clinically significant interactions? A. Clopidogrel B. Aspirin C. Warfarin D. Heparin

C. Warfarin Patients on warfarin need to be closely monitored about what other medications they are on and what foods they ingest.

A patient was started on warfarin two days ago. He asked his nurse why he is still having to take his heparin? How should the nurse respond? A. Warfarin and heparin are often used in combination long-term to prevent clotting. B. That sounds like a mistake, I will speak with the provider about discontinuing the heparin therapy immediately. C. Warfarin can take 3-5 days to begin working. D. Warfarin doses are highly variable and until the INR stabilizes, you will need to continue with heparin.

C. Warfarin can take 3-5 days to begin working. Warfarin works to prevent clotting factor synthesis, but the effects will not be noticeable until current clotting factors are used up in ~ 3-5 days. Heparin works during that time as the primary anticoagulant.

A woman has been ordered bed rest for the remaining 6 weeks of her pregnancy. She has a family history of clotting disorders. Which anticoagulant would likely be prescribed prophylactically? A. Warfarin B. Aspirin C. Unfractionated heparin D. Dalteparin

D. Dalteparin Dalteparin is a LMWH. Heparin does not cross the placenta, and LMWH lower the risk of thrombocytopenia. They are good for prophylactic use.

A patient is undergoing a PCI and is on an infusion of abciximab. Once the procedure is complete, the infusion is stopped. How long will the antiplatelet action continue? A. 3-5 days until new platelets are synthesized B. 12 hours C. 2 hours D. Immediately

D. Immediately The reversible antiplatelet properties only work during the infusion. The patient may require additional oral anticoagulant therapy to continue at home.

A patient is being treated for DVT. The nurse notifies the provider before administering dabigatran (Pradaxa) because: A. The client has atrial fibrillation B. The nurse has not yet received the results of the INR. C. The ordered dose is 150 mg twice a day. D. The client is 86 years old.

D. The client is 86 years old. The risk of severe bleeding increases in patients over 75 years old. This medication is indicated for patients with afib and requires no blood monitoring.