Clotting - NCO - 4th
After a prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. Which nursing goal will best achieve prevention? 1 Increase coagulability of the blood. 2 Increase velocity of the venous return. 3 Increase effectiveness of internal respiration. 4 Increase oxygen-carrying capacity of the blood.
Correct 2 Increase velocity of the venous return. Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. Effectiveness of internal respiration and oxygen-carrying capacity of the blood will not affect the prevention of deep vein thrombosis.
After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1 Observing the suprapubic dressing for drainage 2 Maintaining the client in the semi-Fowler position 3 Monitoring for bright red blood in the drainage bag 4 Encouraging fluids by mouth as soon as the gag reflex returns
Correct 3 Monitoring for bright red blood in the drainage bag Blood clots are normal 24 to 36 hours after surgery, but bright red blood can indicate hemorrhage. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler position. The client is initially allowed nothing by mouth and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
Before a cholecystectomy, vitamin K is prescribed. The nurse recognizes that this is ordered because vitamin K contributes to the formation of which substance? 1 Bilirubin 2 Prothrombin 3 Thromboplastin 4 Cholecystokinin
2 - Prothrombin Vitamin K is necessary in the formation of prothrombin to prevent bleeding. It is a fat-soluble vitamin and is not absorbed from the gastrointestinal (GI) tract in the absence of bile. Bilirubin is the bile pigment formed by the breakdown of erythrocytes. Thromboplastin converts prothrombin into thrombin during the process of coagulation. Cholecystokinin is the hormone that stimulates contraction of the gallbladder.
An adolescent is admitted with an acute hemophilia episode. For what are rest, ice, compression, and elevation most helpful? 1 Encouraging immobilization 2 Decreasing swelling and inflammation 3 Providing pain relief and reducing anxiety 4 Controlling bleeding and retaining joint function
Correct 4 Controlling bleeding and retaining joint function Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints. Reducing inflammation is not the goal of treatment for the hemophiliac process. Total immobilization is not required. Pain may be relieved to some degree but is not assured.
A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply. 1 Avoid intramuscular injections 2 Institute neutropenic precautions 3 Monitor the white blood cell count 4 Administer prescribed anticoagulants 5 Examine the skin for ecchymotic areas
1 Avoid intramuscular injections 5 Examine the skin for ecchymotic areas Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrombocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 1 Poached eggs 2 Spinach salad 3 Sweet potatoes 4 Cheese sandwich
2 Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.
The nurse is caring for a client with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of what symptom? 1 Pruritus 2 Bleeding 3 Flatulence 4 Hypokalemia
2 Bleeding Obstruction of bile flow impairs absorption of phytonadione, a fat-soluble vitamin; prothrombin is not produced, and the clotting process is prolonged. Although deposition of bile salts in the skin may lead to pruritus, this is not life threatening. Although there may be an increase in flatulence with biliary disease, it is not life threatening. Obstructive jaundice does not affect potassium levels.
A nurse is performing an assessment on a client with probable acute lymphocytic leukemia (ALL). Which clinical manifestation will the nurse expect to be present? 1Alopecia 2 Insomnia 3 Ecchymosis 4 Hypertension
3 Ecchymosis Bleeding tendencies occur because of bone marrow suppression and rapidly proliferating leukocytes. Alopecia is associated with chemotherapy; there is no change in hair with leukemia. The client more likely will be sleeping excessively. Hypertension is not a clinical manifestation of leukemia.
A nurse is caring for a client who had a splenectomy. Which complication in the immediate postoperative period is priority for the nurse to assess for in this client? 1 Infection 2 Peritonitis 3 Hemorrhage 4 Intestinal obstruction
3 Hemorrhage Because the spleen is highly vascular, hemorrhage may occur, and abdominal distention results. Although an elevated temperature is common, usually it is not the result of infection; the incidence of infection is higher after a splenectomy, but it does not occur in the immediate postoperative period. The incidence of intestinal obstruction is not higher than for other abdominal surgery and does not take priority over hemorrhage.
Warfarin is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. What rationale does the nurse include to address the client's concern? 1 This permits the administration of smaller doses of each medication. 2 Giving both drugs allows clot dissolution while preventing new clot formation. 3 Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. 4 Administration of heparin with warfarin provides immediate and maximum protection against clot formation.
3 Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Warfarin is administered orally for 2 to 3 days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.
The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? 1 To promote healing of the incision 2 To decrease the incidence of urinary tract infections 3 To use energy to help the client sleep better at night 4 To keep blood from pooling in the legs to prevent clots
4 To keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.
An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. What does the nurse identify as the reason that the crisis occurred? 1 Severe depression of the circulating thrombocytes 2 Diminished red blood cell (RBC) production by the bone marrow 3 Pooling of blood in the spleen with splenomegaly as a consequence 4 Blockage of small blood vessels as a result of clumping of RBCs
4 Blockage of small blood vessels as a result of clumping of RBCs The red blood cells in sickle cell anemia are fragile. When hypoxia or dehydration occurs, the cells take on a crescent shape; they then clump together and occlude blood vessels. The platelet count is not severely depressed in vaso-occlusive crisis. Diminished RBC production by the bone marrow is an aplastic crisis resulting in severe anemia. Pooling of blood in the spleen that results in splenomegaly is known as a splenic sequestration crisis.
What is the cause of Sheehan's syndrome? 1 Thinner bones 2 Intolerance to cold 3 Severe hypotension 4 Postpartum hemorrhage
4 Postpartum hemorrhage Sheehan's syndrome is observed in clients during postpartum hemorrhage manifested by pituitary infarction resulting in decreased hormonal secretion. Severe hypotension reduces blood flow to the pituitary gland leading to hypoxia and infarction, which causes hypopituitarism. Thinner bones are seen in clients with growth hormone deficiency. Intolerance to cold is observed in clients with thyroid hormone deficiency.
The nurse is teaching a group of student nurses about emergency treatment procedures for the local complication of intravenous therapy involving thrombosis. Which statements made by the student nurse require correction? Select all that apply. 1 "I should lower the extremity of the client." 2 "I should apply warm compresses to stabilize the clot." 3 "I should apply cold compresses to decrease the blood flow." 4 "I should use low dose thrombolytic agent that can lyse the clot." 5 "I should stop the infusion, but keep the short peripheral catheter in place."
Correct 1 "I should lower the extremity of the client." Correct 2 "I should apply warm compresses to stabilize the clot." Correct 5 "I should stop the infusion, but keep the short peripheral catheter in place. It is essential that the nurse elevate the extremities of the client. The nurse should always use cold compresses, not warm, to stabilize the clot in case of thrombosis. The nurse should stop the infusion and should remove the short peripheral catheter rather than keeping it in place. It is imperative for the nurse to use cold compresses to decrease the blood flow in case of thrombosis. The nurse should use a low dose thrombolytic agent that can help in lysing the clot.
