Cardiac: PVD: DVT
The client diagnosed with a DVT is on heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin.
1. Check the PTT and PT/INR. Rationale: The nurse should check the laboratory values pertaining to the medications before administering the medications. Why it's not the rest: The heparin is to cover the client at a therapeutic level while the Coumadin takes longer to reach (the heparin will be discontinued once the Coumadin has reached a therapeutic level). The laboratory levels should be noted before administering the medications.
Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who has had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.
1. The client diagnosed with DVT who complains of pain on inspiration. Rationale: A potentially life threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a PE. Why it's not the rest: A immobile client should be turned every two (2) hours, but a pressure area is not life threatening. It is common for clients recovering from an abdominal surgery, because it hurts to breathe; the nurse should address this client, but it is not life-threatening. It is an expected outcome of inguinal hernia repair to have difficulty voiding.
The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. 2. The client who is one (1) day post operative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged. 4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. Rationale: A complication of immobility after surgery is developing a DVT. This client with left calf pain should be assessed for a DVT. Why it's not the rest: Option 2 is an expected finding. Option 3 requires the client needing discharge training in regards to the care of their tube; this does not supersede possible surgical complications. Option 4 is an expected finding.
Which actions should the surgical scrub nurse take to prevent personally developing a DVT? 1. Keep the legs in dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have an elevated heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery.
2. Flex the leg muscles and change the leg positions frequently. Rationale: Flexing the leg muscles and changing positions assist the blood to return to the heart and move out of the peripheral vessels. Why it's not the rest: Keeping the legs dependent and standing still will promote DVT development. The nurse should wear support stockings, not socks, and change the types of shoes worn from day to day, varying the type of heels. Taking a break is not in the client's best interest.
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every four (4) hours and PRN. 5. Assess Homans' sign every 24 hours.
2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every four (4) hours and PRN. Rationale: Clients should be on bedrest for five (5) to seven (7) days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing an embolism, Bedrest and limited activities predispose the client to constipation; fluids and diets high in fiber will help prevent constipation, and will also help provide adequate fluid volume in the vasculature. The client will be administered a heparin IV drip, which should be monitored. Why it's not the rest: Sequential compression devices provide gentle pressure of the legs to prevent DVT, but are not used as a treatment as they could cause the clot to break loose. Homans' sign is assessed to determine if a DVT is present, and the client has already been diagnosed with one.
The nurse and an UAP are bathing a bedfast client. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain before undressing the client. 2. The UAP begins to massage and rub lotion into the client's calf. 3. The UAP tests the temperature of the water with the wrist before starting. 4. The UAP collects all the linens and supplies and brings them to the room.
2. The UAP begins to massage and rub lotion into the client's calf. Rationale: The UAP could dislodge a blood clot in the leg when massaging the calf. The UAP can apply lotion gently, being sure not to massage the leg. Why it's not the rest: Closing the door and curtain provide client privacy. Testing the water prevents scalding the client or making the client uncomfortable with too cold water. Collecting all supplies prior is using time wisely and avoids interrupting the bath.
The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT is 46 seconds. The heparin comes in 500 mL of D5w with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?
20 mL/hr
The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green, leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top.
3. Avoid green, leafy vegetables and notify the HCP of red or brown urine. Rationale: Green, leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods interfere with the action of warfarin. Red or brown urine may indicate bleeding. Why it's not the rest: PT/INR is monitored, not PTT, and it should be monitored usually every two (2) to (3) weeks up to six (6) month intervals. The client is not restricted to the home; the client should not take part in any activity that does not allow frequent active and passive leg exercises. The client should be instructed to wear stockings that do not constrict any area of the leg.
The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhagic areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client's PTT level. 3. Explain this results from the medication. 4. Assess the client's vital signs.
3. Explain this results from the medication. Rationale: This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication. Why it's not the rest: This occurs from the administration of the LMWH and is not a reason to notify the HCP. A therapeutic range will not be achieved with LMWH, and PTT levels are usually not done. Assessing vital signs will not provide any pertinent information to help answer the client's question.
The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor? 1. Blood urea nitrogen (BUN) levels. 2. Bilirubin levels. 3. International normalized ratio (INR). 4. Partial thromboplastin time (PTT).
3. International normalized ratio (INR). Rationale: PT/INR is a test to monitor warfarin (Coumadin) action in the body. Why it's not the rest: BUN laboratory tests are measurements of renal functioning. Bilirubin is a over function test. PTT levels monitor heparin activity.
The home health nurses admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs.
3. The client takes vitamin E over-the-counter medication. Rationale: Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin. Why it's not the rest: There is nothing that contraindicates the use of a stool softener, and use of one may be recommended. A Medic Alert bracelet notifies any emergency HCP of the client's condition and medications. A new recliner would be recommended for the client if the footrest does not restrict blood flow in the calves.
The male client is diagnosed with Guillain-Barre (GB) syndrome and is in the ICU on a ventilator. Which cardiovascular rationale explains implementing passive ROM exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help prevent DVTs by movement of blood through the veins.
4. They help prevent DVTs by movement of blood through the veins. Rationale: One reason for performing ROM exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT. Why it's not the rest: Contractures are a musculoskeletal complication, not a cardiovascular (passive ROM should be used here as well). If the client is on a ventilator than then the paralysis has moved up the spinal cord to include the respiratory muscles; therefore the client would be unable to perform the ROM exercises himself. ROM exercises won't alleviate GB pain.
