DVT, PE, and CVA ADN 420

Which client statement demonstrates an accurate understanding of the action of a prescribed anticoagulant?

"This medication will keep unnecessary clots from forming in my blood."

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.

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?

Call the rapid response team

A 50-year-old client has undergone a bunionectomy and has been admitted to the postsurgical unit. What aspect of the client's medical history would contraindicate the use of heparin for deep vein thrombosis (DVT) prophylaxis?

Diagnosis of ulcerative colitis

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

A client has a transverse fracture of the left humerus. Which assessment indicates a developing complication?

New onset of shortness of breath

A 40-year-old male presents to the emergency department reporting chest pain and shortness of breath. The health care provider suspects a pulmonary embolism and orders several diagnostic tests. Select the test that would require further follow-up.

Positive D-dimer

A 74-year-old woman states that many of her peers underwent hormone replacement therapy (HRT) in years past. The woman asks the nurse why her primary care provider has not yet proposed this treatment for her. What fact should underlie the nurse's response to the woman?

The risks of stroke and breast cancer are unacceptably high in women taking HRT.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

a client who is on complete bed rest following extensive spinal surgery a client who has a large venous stasis ulcer on the right ankle area a client who has recently been admitted with a broken femur and is awaiting surgery a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

severe exploding headache

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4

Which client would be the best candidate to receive alteplase recombinant therapy?

A 68-year-old male who has had an ischemic stroke that resulted in neurological deficits

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

An obese woman with a history of atrial fibrillation and type 2 diabetes

A 55-year-old client has been diagnosed with coronary artery disease and begun antiplatelet therapy. The client has asked the nurse why a "blood thinner like warfarin" hasn't been prescribed. What is the most likely rationale for the clinician's use of an antiplatelet agent rather than an anticoagulant?

Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis.

The nurse is reviewing the medication administration record of a female client who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?

Aspirin 81 mg PO o.d.

While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client?

Assess the respiratory status every 4 hours.

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

Fat embolism syndrome

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?

Frequent neurologic checks

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?

Increase the oxygen flow rate from 2 to 4 L/min.

The nurse is caring for a client who develops sudden onset dyspnea. Which assessment should the nurse prioritize to best identify if the cause may be a pulmonary embolism?

Lower limb appearance

The nurse is caring for a client who is going home on warfarin. What lab test(s) will the client require to evaluate therapeutic effects of the drug?

Prothrombin time (PT) and international normalized ratio (INR)

A patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions?

Pulmonary embolism

The client's ultrasound shows a thrombus in the venous sinus in the soleus muscle. The nurse explains that early treatment is important to prevent:

Pulmonary embolism

What laboratory value will the nurse prioritize when providing care for a client prescribed intravenous heparin?

aPTT

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply.

activity intolerance related to inadequate oxygenation anxiety related to breathlessness ineffective breathing pattern related to hypoxia risk for decreased cardiac output related to failure of the left ventricle

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?

Provide close supervision because of the client's impulsiveness and poor judgment.