Clotting Prep u
A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition?
Arterial thrombosis Explanation: A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.
A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?
Assess the fundus and massage it if it's boggy.
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?
DIC is caused by an abnormal activation of clotting pathway causing excessive amounts of tiny clots to form inside organs.
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?
uterine atony
The health care provider discovers a clot in the client's left lower leg. Anticoagulant drugs are prescribed to prevent formation of new clots and to achieve which other effect?
Prevent extension of clots already present Explanation: Anticoagulant drugs are given to prevent formation of new clots and extension of clots already present.
A client with a diagnosis of hemophilia A has been admitted with bilateral knee pain. The nurse should anticipate performing what intervention during the client's treatment?
Administration of factor VIII and implementation of fall prevention measures Explanation: Clients with hemophilia have a deficit in factor VIII. Administration of vitamin K, platelets, or DDAVP is ineffective because of the absence of this clotting factor. Injury prevention is paramount in the care of a client with a bleeding disorder.
A client, 6 hours post-birth, has a severe postpartum hemorrhage that the health care providers are unable to control. She succumbed to the hemorrhage in the intensive care unit. The client's death would become part of the:
maternal mortality rate.
The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as
petechiae. Explanation: Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL
Disseminated intravascular coagulation (DIC) is a grave coagulopathy resulting from the overstimulation of clotting and anticlotting processes in response to:
Disease or injury Explanation: Disseminated intravascular coagulation is a paradox in the hemostatic sequence and is characterized by widespread coagulation and bleeding in the vascular compartment. It is not a primary disease but occurs as a complication of a wide variety of conditions such as disease or injury (e.g., septicemia, acute hypotension, poisonous snake bites, neoplasms, obstetric emergencies, severe trauma, extensive surgery, and hemorrhage)
In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?
hemorrhage
Client's 24 hour blood loss is 600mL. Uterus is soft and relaxed on palpation and client has a full bladder. Assisted client in emptying bladder and notified the MD. Vitals are stable at present. See graphic sheet for ongoing assessments and perineal pad weights. A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed
postpartum hemorrhage
A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal and the client is not in labor. Which nursing intervention should the nurse perform?
Monitor the amount of vaginal blood loss.
A 44-year-old woman has developed calf pain during a transatlantic flight. She is extremely short of breath upon arrival at her destination. She was subsequently diagnosed with a pulmonary embolism (PE) that resolved with anticoagulant therapy. Which statement best characterizes the underlying problem of her PE?
Ventilation was occurring but perfusion was inadequate, causing shortness of breath. Explanation: Impaired blood flow to a portion of the lung, such as with a PE, is associated with ventilation without perfusion, rather than perfusion without ventilation. The situation is not related to an anatomic shunt or impaired diffusion across alveolar membranes.
The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply.
blood pressure higher than 160/110 mm Hg upper right quadrant pain epigastric pain hyperbilirubinemia ?
A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth?
postpartal hemorrhage
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?
Assessing fetal heart tones by use of an external monitor
One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?
Consistency, shape, and location Explanation: Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.
A pregnant adolescent admitted with premature uterine contractions was successfully treated with I.V. fluids. She is eager to return to high school to take a math test. The nurse's discharge examination reveals vaginal blood pooling under the adolescent's buttocks that's painless to the client. Which action should the nurse take?
Stop the discharge process and notify the physician immediately.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?
The client will be immobile during and shortly after surgery.
A female client is admitted to the hospital for treatment of a pulmonary embolism. Forty-eight hours after therapy has started, the client reports bleeding from her gums when she brushes her teeth. What orders can the nurse anticipate receiving from the health care provider to reverse the effects of the heparin?
Administer protamine sulfate, at a dosage of 1 mg per 100 units of heparin, for a maximum dose of 100 mg. Explanation: If a client receives an overdose of heparin or shows signs of bleeding, then protamine sulfate, the antagonist for heparin, may be administered. Protamine sulfate, a strong base, reacts with heparin, a strong acid, to form a stable salt, thereby neutralizing the anticoagulant effects of heparin. The protamine sulfate dose is based on the heparin dose: 1 mg of protamine sulfate per 100 units of heparin. No more than 100 mg of protamine sulfate should be given within a 2-hour period, because this drug can cause anticoagulation in its own right.
A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be:.
antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn. Explanation: Antiepileptic therapy may cause vitamin K-deficient hemorrhage of the newborn that the vitamin K injection the newborn receives following birth cannot fully correct. Therefore, some physicians recommend a Vitamin K supplement for their pregnant patients beginning at 36 weeks' gestation. If the mother should go into preterm labor, the newborn will have received the vitamin K prior to delivery. However, many physicians now question the usefulness of the prophylaxis
A client at risk for deep vein thrombosis (DVT) is prescribed antiembolism stockings. What should the nurse instruct the client about the purpose of these stockings?
promotes venous blood return from the extremities
Place the steps of fibrin clot breakdown in correct order. Formation of plasmin Activation of plasminogen Release of fibrin degradation products Digestion of fibrinogen and fibrin
Activation of plasminogen Formation of plasmin Digestion of fibrinogen and fibrin Release of fibrin degradation products Explanation: As an injured vessel is repaired and again covered with endothelial cells, the fibrin clot is no longer needed. Plasminogen is needed to break down the fibrin. The fibrin clot breakdown begins with activation of plasminogen, which forms plasmin. Plasmin acts to digest fibrinogen and fibrin, which releases fibrin degradation products and completes the fibrin clot breakdown.
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?
Disseminated intravascular coagulation (DIC)
The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client?
Ensure a safe environment. Explanation: Providing a safe environment protects the child from injury. This is important because the child is at risk for bleeding due to the thrombocytopenia. The other options are important for a child with cancer, but are not the priority in relation to thrombocytopenia.
A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action?
Evaluate the client's platelet count. Explanation: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.
A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?
Fetal heart rate of 80 beats/minute
Which class of medication lyses and dissolves thrombi?
Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.
A patient is being treated for chronic venous stasis ulcers of the lower extremities. What medication does the nurse understand will increase peripheral blood flow by decreasing the viscosity of blood and assist with the healing of the ulcers?
Pentoxifylline (Trental) 0p9Explanation: Some oral medications may accelerate healing chronic venous ulcers of the lower legs. Pentoxifylline (Trental) increases peripheral blood flow by decreasing the viscosity of blood. It has some fibrinolytic action and decreases leukocyte adhesion to the wall of the blood vessels.
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?
Prepare to administer protamine sulfate. Explanation: Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.
A 6-month-old boy has been admitted to the hospital with severe bloody diarrhea. The nurse notes petechiae and eczema with signs of secondary infection. As the nurse documents the boy's history, the parents report easy bruising and prolonged bleeding after circumcision. Based on these findings, the nurse suspects a diagnosis of:
Wiskott-Aldrich syndrome. Explanation: Severe bloody diarrhea, petechiae, bruising, eczema with secondary infection, and prolonged bleeding episodes are signs and symptoms of Wiskott-Aldrich syndrome. Beta-thalassemia major would be manifested by signs of bleeding. von Willebrand disease would be manifested by signs of bleeding. Severe combined immunodeficiency would be manifested by chronic diarrhea and failure to thrive, persistent thrush, and a history of severe infections beginning in infancy.
A teenage girl, seen in the clinic, is diagnosed with nonthrombocytopenic purpura. The girl states, "You have taken a lot of blood from me. Which of my tests came back abnormal?" How should the nurse respond?
Your CBC with differential showed a normal platelet count. Explanation: In persons with bleeding disorders caused by vascular defects, the platelet count and results of other tests for coagulation factors are normal. A shift to the left indicates an infectious or inflammatory process, not a clotting disorder. A lack of iron indicates iron deficiency anemia, not a clotting disorder. A normal hematocrit indicates a normal number of packed red blood cells, not a clotting disorder.
The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider? Select all that apply. a white blood cell count of 18,000 a hemoglobin of 7.2 gm/dL a potassium level of 4.2 mEq/L a BUN of 9 mg/dL a sodium level of 128 mEq/L increased hemoglobin level, indicating infection
a white blood cell count of 18,000 a hemoglobin of 7.2 gm/dL a sodium level of 128 mEq/L Explanation: Significant abnormal findings include an elevated white blood cell count (presence of infection), decreased hemoglobin level (presence of bleeding, anemia), and a sodium level of 128 mEq/L which is dangerously low and can lead to seizures or death if not corrected. A BUN/ of 9 is within normal range as is a potassium level of 4.2.
A 51-year-old man is being discharged from the hospital following treatment with anticoagulants for a deep vein thrombosis. The nurse will instruct the client to:
consider safety measures to prevent bleeding and be alert for signs of bleeding.
A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP?
elevated lipoproteins
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?
hemorrhage
A woman who had a cesarean birth of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect?
pulmonary emboli
A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?
. "knife-like" abdominal pain with vaginal bleeding
The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?
1 hour Explanation: A transient ischemic attack (TIA) is a neurologic deficit typically lasting less than 1 hour. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.
Which of the following medications is considered a thrombolytic? Alteplase Heparin Coumadin Lovenox
Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next?
Assessment of the perineal pad
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?
To check for postpartum hemorrhage
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which of the following client statements indicates that the teaching was successful?
"I might need to have this procedure done again." Explanation: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.
A patient has received a heterograft for a tricuspid valve replacement. What statement made by the patient demonstrates understanding of the valve replacement?
"I will not take long-term anticoagulation because I want to get pregnant." Explanation: Bioprostheses are tissue valves (e.g., heterografts) used for aortic, mitral, and tricuspid valve replacement. They are not thrombogenic; therefore, patients do not need long-term anticoagulation therapy. They are used for women of childbearing age because potential complications of long-term anticoagulation associated with menses, placental transfer to a fetus, and delivery of a child are avoided. They also are used for patients older than 70 years, patients with a history of peptic ulcer disease, and others who cannot tolerate long-term anticoagulation. Most bioprostheses are from pigs (porcine), but some are from cows (bovine) or horses (equine). They may be stented or nonstented. Viability is 7 to 15 years
Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?
Reinforce the need to perform leg exercises every hour when awake
A nurse is caring for a client with sepsis who was recently transferred to the intensive care unit following the development of disseminated intravascular coagulation (DIC). The nurse understands that DIC is most likely secondary to the infection causing the release of cytokines, which can cause: Severe soft-tissue hemorrhages Petechiae, purpura, and renal failure Oozing from puncture sites and hypertension Amenorrhea and black, tarry stools
Petechiae, purpura, and renal failure Explanation: DIC is a condition causing the presence of both inappropriate clotting and episodes of bleeding, as in the presence of petechiae, purpura, and renal failure. The production of microemboli obstruct the blood vessels, causing multiorgan failure; bleeding occurs because all the coagulation proteins and platelets are used up by clot formation.
A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia GERD
kidney failure disseminated intravascular coagulation acute respiratory distress syndrome Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.
A 3-year-old child presents with bruising and mucous membrane bleeding from the nose and mouth. The nurse knows that these symptoms are indicative of:
von Willebrand disease. Explanation: von Willebrand disease occurs because there is a deficiency of the von Willibrand factor. This factor is responsible for binding factor VIII, protecting this "glue that attaches platelets to the site of injury from breakdown. The primary clinical manifestations of von Willebrand disease are bruising and mucous membrane bleeding from the nose and mouth. Bleeding may be mild or can become severe and lead to anemia and shock. Deep bleeding into joints and muscles is rare. This is typically associated with hemophilia. A child does not bleed with iron-deficiency anemia. The child with DIC would be bleeding from every orifice.
A client 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. Explanation: Gingko biloba affects platelet function and thus should not be used concurrently with aspirin or warfarin.
The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents?
Administer factor VIII intravenously at the first sign of bleeding Explanation: Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, however, playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided because they will interfere with platelet aggregation. Nasal packing is avoided because when the nasal packing is removed, bleeding may occur.
A pregnant woman contacts her physician because she has developed sudden, severe pain and swelling in her left lower leg. The physician explains to her that her past medical includes an inherited defect in factor V Leiden, which predisposes her to the development of:
Excessive clotting Explanation: Factor V Leiden is an inherited clotting disorder. The normal factor V gene is replaced by the factor V Leiden gene, which is harder for normal anticoagulants to inactivate. The inability to inactivate factor V Leiden predisposes a person to developing blood clots, and the prothrombic situation that occurs with pregnancy increases the risk of thrombosis.
In a postmenopausal woman with abnormal vaginal bleeding, which diagnostic test would the nurse expect the primary care provider to determine whether an endometrial biopsy is needed?
transvaginal ultrasound Explanation: In this situation, a transvaginal ultrasound is used to measure the endometrial thickness to determine if an endometrial biopsy is needed. CA-125 is a nonspecific blood test used as a tumor marker. A Papanicolau test aids in detecting abnormal cells of the cervix. A mammogram detects calcifications, densities, and nonpalpable cancer lesions of the breast.
What would be the physiologic basis for a placenta previa?
low placental implantation
The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?
pulmonary embolism Explanation: Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.
The nurse is caring for a group of postoperative clients. The client with what characteristics will the nurse assess as at highest risk for deep vein thrombosis? -the client who usually walks 3 miles (4.8 kilometers) a day -the client who will be immobile during and shortly after surgery -the client who is 5 feet 9 inches (172.5 cm) tall and weighs 128 lb (58 kg) -the client who is a gravida IV whose last child was born 3 years ago
the client who will be immobile during and shortly after surgery
A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client?
Administer cryoprecipitate and platelets. Explanation: In a pregnant client with DIC, the nurse may be told to administer cryoprecipitate and platelets. Whole blood does not contain clotting factors. Therefore a ratio of 4 units of blood to 1 unit of fresh frozen plasma, and not 1 unit of blood to 4 units of frozen plasma, should be considered. The nurse should aim at maintaining the client's hematocrit above 30% and not just 20%. The nurse should expect one unit of blood to increase the hematocrit by 1.5 g/dL not 3g/dL.
The nurse is planning care for a school-aged child recovering from being hit by a motor vehicle while riding a bicycle. For what will the nurse assess to determine the onset of disseminated intravascular coagulation in this child?
Bleeding from intravenous sites
Which of the following are alterations noted in Virchow's triad? Select all that apply. Stasis of blood Vessel wall injury Altered coagulation Edema Tenderness
Stasis of blood Vessel wall injury Altered coagulation Explanation: Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.
Based on the nurse's knowledge of the increased risk for bleeding in a client undergoing chemotherapy or radiation, which of the following interventions does the nurse need to include in the client's plan of care? Select all that apply.
Monitoring the platelet count Monitoring for signs of abnormal bleeding Instructing the client to use a soft toothbrush Instructing the client to use an electric razor Explanation: Utilizing critical thinking skills, the nurse knows to implement individualized interventions to reduce the client's risk of bleeding. Hence, the nurse must frequently assess platelet counts, monitor for signs of abnormal bleeding, and instruct the client and family about ways to minimize bleeding, such as using a soft toothbrush and/or an electric razor. Medications that may interfere with clotting, such as aspirin, should be avoided, and blood draws and injections should be kept to a minimum.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta
Which nursing assessment finding indicates the client with traction has not met expected outcomes?
Right calf warm and swollen
Which would the nurse identify as the end of the intrinsic pathway? Thrombin formation Vasoconstriction Platelet aggregation Release of factor XI
Thrombin formation Explanation: Thrombin formation occurs at the end of the intrinsic pathway. The first reaction to a blood vessel injury is local vasoconstriction. In addition, injury then exposes blood to the collagen and other substances under the endothelial lining of the vessel causing platelet aggregation. Release of factor XI occurs in response to activation of the Hageman factor.
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
Uterine atony
The postmenopausal woman who has bleeding and spotting and cannot tolerate a endometrial biopsy in the office would have which test done to rule out endometrial cancer?d Papanicolau test are not used to diagnose this disease.
transvaginal ultrasound Explanation: If an endometrial biopsy is inconclusive for cancer, then the client would have a transvaginal ultrasound to evaluate the endometrial cavity and measure the thickness of the endometrial lining. A pelvic examination and Papanicolau test are not used to diagnose this disease.
A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching? "I maintain a high fluid intake." "I'll try not to stand for long periods." "I dorsiflex my feet and ankles frequently." "I wear knee-highs rather than pantyhose."
"I wear knee-highs rather than pantyhose." Explanation: Women with varicosities should not wear knee-high stockings as they put pressure on leg veins and reduce venous return.
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?
Oxytocin
A client in the hospital following a repair of a left hip fracture is refusing to wear the intermittent pneumatic compression stockings ordered by the physician. The nurse explains to the client that the compression stockings are essential in preventing:
Venous thrombosis
