HESI CASE STUDY: Deep Vein Thrombosis

Heparin Therapy: Math The HCP prescribes: Administer IV bolus dose of heparin 80 units per kg of body weight. The heparin bolus is available in a 1,000 unit/mL concentration. The client weighs 165 lbs. Initiate continuous IV infusion of 500 mL of 5% Dextrose in water with 25,000 units of heparin at a rate of 22 units of heparin per kg of body weight per hour. What is the correct IV bolus dose of heparin the nurse should administer? (Enter numerical value only. If rounding is necessary, round to the tenth.)

ANSWER: 6ml TV(x)DF= TM *Asking for correct IV bolus dose *convert 165lbs to kg; 165lbs=75kg 80units(x)75kg(divided)1,000unit/ml 80(X)75=6000 6000(divide)1,000=6ml

The client should also be instructed to avoid which over-the-counter (OTC) products? (Select all that apply. One, some, or all options may be correct.) A) Calcium carbonate. B) Antihistamines. C) Aspirin, salicylates, ibuprofen and naproxen. D) Garlic. E) Acetaminophen.

ANSWERS: A,C,D,E A) Calcium carbonate: There are many drug interactions with warfarin. Instruct the client to consult with HCP before taking any OTC products. C) Aspirin, salicylates, ibuprofen and naproxen: Inhibits clotting and can cause serious bleeding. D) Garlic: Inhibits clotting and can cause serious bleeding. E) Acetaminophen: Acetaminophen is not recommended for the client taking warfarin as risk exists for increased bleeding.

Another less common complication of heparin therapy is Heparin Induced Thrombocytopenia (HIT). What if the client develops fever and chills? Based on these cues, the nurse recognizes that it is essential to obtain which information first? A) Platelet count. B) White blood cell count (WBC). C) Renal function tests. D) Client's fluid intake and output.

A) Platelet count To detect HIT, observe the client for decreasing platelet count, skin lesions at the injection site, and systemic reactions such as chills and fever.

The nurse contacts the HCP and receives prescriptions to obtain another APTT at 0600 hours and to decrease the heparin infusion to 30 mL/hour. At the change of shift, the nurse reports to the oncoming nurse the new prescriptions and the lab test results: APTT = 70, control APTT = 35. When the oncoming nurse enters the client's room, the IV pump is infusing at 50 mL/hour. The incoming nurse notices which cue as the cause of observable hematuria in the client's urinary catheter? A) The IV pump infusing at a higher rate than prescribed. B) The HCP prescribes a lower rate than recommended. C) The day shift nurse reported lowering the rate of infusion prior to shift change. D) The urinary catheter bag hangs from the side bedrail.

A) The IV pump infusing at a higher rate than prescribed. The nurse should recognize the cue that the IV pump is infusing at 50 mL/hour instead of prescribed rate of 30 mL/hour.

What is the legal concern involved in this situation? A) Assault. B) Fraud. C) Defamation D) Malpractice

ANSWER: D) Malpractice: Malpractice is negligence by the professional person and in this case, the nurse did not act according to professional standards of care as a reasonable and prudent professional would. NOT B/C: A) Assault: Assault is the threat to harm another, or even threaten to touch another without the person's permission. B) Fraud: Fraud occurs when a person intends to deceive others by unjustifiably claiming or being credited with accomplishments or qualities. C) Defamation: Defamation is when one person makes remarks about another person that are untrue, and the remarks damage that other person's reputation.

Which non-pharmacologic nursing interventions will reduce pain related to decreased venous flow? (Select all that apply. One, some, or all options may be correct.) A) Apply cold packs. B) Elevate the affected leg. C)Gently massage the affected leg. D)Encourage occasional ambulation. E) Apply a warm compress.

ANSWER: B) Elevate the affected leg: Keep leg elevated when sitting. Prevents pooling of blood and edema. E) Apply a warm compress: Heat increases the flood flow to that area resulting in decreased pain.

Refer to the HCP prescription and calculate the continuous infusion rate for the IV dosage of heparin. _____units/hr.

ANSWER: 1,650 units/hr 22 units/kg/hr. x 75 kg = 1,650 units/hr.

At what rate should the IV pump be set to deliver the prescribed rate of infusion? (Enter numerical value only. If rounding is necessary, round to the whole number.) ____mL/hr

ANSWER: 33 mL/hr. 22 units/kg x 75 kg = 1,650 units On hand = 25,000 units : 500 mL: 1,650 units : X mL = Solution Using Ratio and Proportion: 25,000x = 1,650 x 500 25,000x = 825,000 X= 33 mL/hr.

The client is describing the pain in her right leg as severe and concentrated in her foot and ankle. The nurse receives a prescription from the HCP for hydrocodone bitartrate and acetaminophen 5/325 two tabs PO prior to the client's exam. Before initiating the treatment, it is most important for the nurse to implement which interventions? (Select all that apply. One, some, or all options may be correct.) A) Perform a focused assessment on the lower right extremity. B) Implement a numeric pain assessment on a scale of 1 to 10.Document a baseline of vital signs including a pulse oximetry. C) Use at least two client identifiers before administering the medication. D) Initiate the treatment without further delay because the client is in pain.

ANSWER: A,B,C,D A) Perform a focused assessment on the lower right extremity. B) Implement a numeric pain assessment on a scale of 1 to 10.Document a baseline of vital signs including a pulse oximetry. C) Use at least two client identifiers before administering the medication. D) Use at least two client identifiers before administering the medication.

Based on the nurse's assessment which cues support the decision to provide intervention for the client's pain as the first priority? (Select all that apply. One, some, or all options may be correct.) A) Blood pressure. B) Client's reported pain level of 7/10. C) History of rheumatoid arthritis. D) Recent hip surgery within the last 3 months. E) Examination of the client's right lower extremity. F) All the above

ANSWER: F) All the above A) Blood pressure. The autonomic nervous system responds to pain through sympathetic nervous system responses like elevated blood pressure, pulse, and respiratory rate. B) Client's reported pain level of 7/10. Pain is an individual experience and it is what the client says it is. C) History of rheumatoid arthritis. Rheumatoid arthritis causes chronic pain related to swelling and tenderness of joints. D) Recent hip surgery within the last 3 months. Nursing interventions for clients with recent hip fracture surgery are geared toward relieving pain in order to promote mobility and prevent complications. E) Examination of the client's right lower extremity. Warmth, redness, tenderness and other factors at the site may be causing the pain.

The client needs clear instructions to observe for bleeding tendencies and to initiate behaviors to prevent bleeding. Client teaching should include instructions to report any bleeding, including hemoptysis, melena, hematuria, excessive vaginal bleeding, hematemesis, or bruising. As part of her discharge teaching, the nurse recommends that the client implement several important preventative measures at home. Which interventions are recommended by the nurse? (Select all that apply. One, some, or all options may be correct.) A) Inspect the legs and feet daily. B) Avoid forcefully blowing your nose. C) Shave with an electric instead of a blade razor. D) Briskly message any red, tender areas in the calf E) Use a soft-bristle toothbrush and avoid flossing.

ANSWERS: A,B,C,E A) Inspect the legs and feet daily: The client is instructed to check for bruising that may indicate bleeding. B) Avoid forcefully blowing your nose: Forcefully blowing the nose is a risk for bleeding so the client is instructed to blow the nose gently without blocking either nasal passage. C) Shave with an electric instead of a blade razor: A blade razor shaves closer to the skin and risks cuts and nicks, whereas an electric razor quickly glides over the skin and is less likely to cut and cause bleeding. E) Use a soft-bristle toothbrush and avoid flossing: Any action such as brushing and flossing teeth could initiate bleeding. The client is instructed to mitigate the risk by using a soft-bristle toothbrush.

The client's condition stabilizes and preparations are in progress for discharge from the hospital. The HCP prescribes warfarin therapy in anticipation of the client's discharge to home. Which of the following instructions should the nurse include in the client's teaching plan? (Select all that apply. One, some, or all options may be correct.) A) Teach client to take warfarin as prescribed by HCP. B) The client should wear a medic-alert bracelet. C) The client should notify all future HCPs that she takes warfarin. D) Include green leafy vegetables in diet. E) Follow-up with INR monitoring as prescribed by HCP.

ANSWERS: A,B,C,E A) Teach client to take warfarin as prescribed by HCP: The anticoagulant effect of warfarin may be reversed by omitting one or two doses of the drug so it is important to take warfarin exactly as prescribed by the HCP. B) The client should wear a medic-alert bracelet: Encourage the client to carry an identification card or wear a medical alert bracelet that states they are taking warfarin or any other anticoagulant. C)The client should notify all future HCPs that she takes warfarin: Instruct client to tell dentist and other HCPs before receiving treatment or prescriptions that they are taking warfarin because of the potential for bleeding and drug interactions. E) Follow-up with INR monitoring as prescribed by HCP: Warfarin dose adjustment is based on INR to maintain a therapeutic range.

Heparin overdose can cause life threatening hemorrhaging, such as nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising. Which of these actions should the nurse take for the client's safety? (Select all that apply. One, some, or all options may be correct.) A) Stop the heparin infusion. B) Obtain a stat APTT. C) Assess vital signs. D) Anticipate administering a dose of vitamin K. E) Decrease the infusion rate and contact the HCP. F) Anticipate a prescription of protamine sulfate.

ANSWERS: A,B,C,F A) Stop the heparin infusion: The infusion is stopped until the APTT drops back into a therapeutic range. B) Obtain a stat APTT: APTT must be collected to determine the client's risk for serious spontaneous bleeding. C) Assess vital signs: Vital are always assessed when there is a change in the client's condition. F)Anticipate a prescription of protamine sulfate: Protamine sulfate is the antidote for heparin and vitamin K is the antidote for warfarin. The nurse anticipates administering a dose per the HCP's perscription.

The charge nurse is notified by the night nurse of the medication error. The charge nurse has noticed that some of the staff nurses are unclear about the occurrence report process. The Nurse Educator is notified and prepares an in-service for the unit staff. The Nurse Educator explains to the staff that the incident report is a hospital record that is used by the risk management department. It is a hospital record that helps track patterns of risk to guide corrective action.What information is included in an Incident Report? (Select all that apply. One, some, or all options may be correct.) A) Person who witnessed event writes report. B) Provide assumption about what occurred. C) Injuries resulting from incident. D) Response and corrective measures taken E) Sign and date by the next shift

ANSWERS: A,C,D A) Person who witnessed event writes report: The incident report is used to document what happened, the facts about the incident, and who was involved or witnessed it. The person who witnessed the event writes the report. C) Injuries resulting from incident: Reporting injuries is one of the most important aspects of an incident report. D) Response and corrective measures taken: The nurse's response to an incident is documented and conveyed to the HCP.

Going forward, the nurse continues planning care for the client and gives the highest priority to risk for injury and bleeding related to anticoagulant therapy. Which nursing actions are most important for preventing bleeding complications? (Select all that apply. One, some, or all options may be correct.) A) Ensure that vitamin K is readily available. B) Adjust infusion based on APTT results and institutional protocol. C) Maintain heparin on a continuous infusion pump. D) Monitor platelets daily. E) Apply pressure to venipuncture sites.

ANSWERS: B,C,D,E B)Adjust infusion based on APTT results and institutional protocol: Adjust infusion to maintain anticoagulation within consistent therapeutic levels. C) Maintain heparin on a continuous infusion pump: Continuous intravenous heparin induces a therapeutic anticoagulant response that is monitored based on the client's APTT and must be maintained on a continuous infusion pump. D) Monitor platelets daily: It is important to monitor platelets daily for thrombocytopenia. E) Apply pressure to venipuncture sites: Pressure at puncture sites helps promote clotting.

TREATMENT OF DVT: If the outcome of the diagnostic tests confirm that the client does have DVT, the nurse anticipates the initiation of heparin therapy. Anticoagulants are the drug of choice for clients with actual DVT and so the HCP prescribed Heparin therapy for the client. Which conclusions regarding Heparin administration are accurate? (Select all that apply. One, some, or all options may be correct.) A) Heparin is administered with oral anticoagulation such as warfarin. B) Heparin infusion requires laboratory monitoring and dose adjustment. C) Heparin is known to cause medical complications even death. D) Heparin therapy is administered via intravenous route. E) Protamine sulfate is the anecdote for heparin.

ANSWERS: B,C,D,E B) Heparin infusion requires laboratory monitoring and dose adjustment. C) Heparin is known to cause medical complications even death. D) Heparin therapy is administered via intravenous route. E) Protamine sulfate is the anecdote for heparin.

The nurse checks the Electronic Medical Records (EMR) and acknowledges that the client's coagulation labs are resulted. Client's Results - Base line labs: Complete Blood Count (CBC) Result Range White Blood Cells (WBC) 11 4500-11,000 (3.5-10.5 x 109/L) Red Blood Cells (RBC) 4.05 3.9 - 5.5 x 106/L (3.50-5.0 x 1012/L) Hemoglobin (Hb) 12.3 14.0 - 17.5 g/dL (115-155 g/L) Hematocrit (Hct) 38 41-50% (0.38-0.50 L/L) Platelet count 200 130 - 400 x 109 /L (130-380 x 109/L) Coagulation Panel Prothrombin time (PT) 10 10-13 seconds International Normalized Ratio 0.9 0.9 - 1.2 Partial thromboplastin time(PTT) 35 28 - 38 seconds (22-30 s) When the heparin therapy is initiated, the nurse analyzes which lab value to determine that a therapeutic heparin level has been reached? A) Hemoglobin 9.0 g/dL. (90 g/L) B) APTT 65 seconds, control 35 seconds. C) INR 1. D) Platelet count 250,000/mm3 .

B) APTT 65 seconds, control 35 seconds. Reaching and maintaining a therapeutic level is the most important goal of heparin therapy. Therapeutic levels of APTT are usually 1.5 to 2 times normal control levels. For example, a typical APTT control value is 30-40 seconds so the therapeutic level of APTT should be 60-70 and the HCP should be notified if the APTT value is greater than 70 seconds.

After consulting with the HCP, the nurse is to administer a heparin antagonist. The nurse explains to the client that protamine sulfate is being administered to obtain which expected outcome? A) Neutralize blood clots. B) Reduce hematuria. C) Prevent blood clots. D) Avoid strokes.

B) Reduce hematuria Anticoagulation therapy can lead to excessive bleeding. The antidote for heparin is protamine sulfate.

At the end of the shift, the nurse realizes the UAP has not reported obtaining the stool specimen. The nurse provides privacy before giving criticism and uses which communication approach with the UAP? A) "Why didn't you obtain the stool specimen as you were assigned?" B) "You didn't complete your assignment with the client today." C) "I've noticed that the client's stool specimen was not obtained." D) "I'll go get that stool specimen from the client for you."

C) "I've noticed that the client's stool specimen was not obtained." The nurse should approach the UAP by describing the unacceptable behavior, the expectation for future compliance, and the consequences if the expected action does not occur. It is also important for the nurse to communicate how this affects patient safety and care.

The nurse records the following information the day that the client is scheduled for discharge. Calf circumference equal bilaterally. Prothrombin is 12, INR is twice normal. Oxygen saturation level per oximeter is 98%. Based on these findings, which action should the nurse implement? A) Place the client on oxygen. B) Instruct the client to maintain bedrest. C) Continue with discharge teaching. D) Hold all medication, and contact the HCP.

C) Continue with discharge teaching. The nurse should continue discharge teaching so the client can be released home.

During heparin therapy, the client's APTT is monitored every 6 hours and the midnight results were APTT 120 seconds, control 35 seconds.Based on these cues, what action should the nurse expect to initiate? A) Increase and maintain this rate of infusion until next APTT check in 6 hours. B) Continue and maintain the rate of infusion until the next APTT check in 6 hours. C) Decrease and maintain this rate until the next APTT check in 6 hours. D) Recalculate the infusion rate and maintain this rate until next APTT check in 6 hours.

C) Decrease and maintain this rate until the next APTT check in 6 hours. The nurse should not stop the infusion completely but should decrease the rate according to the prescribed protocol and contact the HCP for further.

The client is scheduled for a venous ultrasound, venography, and coagulation studies. She asks the nurse about the preparation for these tests and what they indicate about her condition. The nurse must educate the client about the venous ultrasound by distinguishing it from the venography. Which description accurately expresses these diagnostic tests? A) Doppler studies and venograms are both invasive procedures. B) Nursing implications for doppler studies include assessment for allergies to iodine and for adequate renal function. C) If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagonis. D) The client must sign an informed consent prior to either of these tests.

C) If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagonis. Accurate scans depend on the technical skill of the health care provider (HCP) performing the test and a venogram may be needed to make diagnosis.

The Joint Commission's National Patient Safety Goals (NPSG) encourages clients and families to have an opportunity for input into their plan of care. Which nursing action is the best for increasing client safety, satisfaction, and continuity of care? A) Communicate end-of-shift report one on one verbally. B) Tape record report for the incoming shift. C) Immediately round on clients after receiving report. D) Nurse-to-Nurse bedside report.

D) Nurse-to-Nurse bedside report: Bedside handoff between shifts allows the client and family to have an opportunity for input into the plan of care. This process helps meet the Joint Commission's National Patient Safety Goals and encourages patients to be an active part of their own care.

The nurse is discussing the client's plan of care with the unlicensed assistive personnel (UAP) assigned to the client. The nurse instructs the UAP the importance of awareness for the increased risk for bleeding related to the anticoagulant therapy. Which action can be delegated by the nurse to the UAP? A) Assess skin for bruising. B) Teach the client to use a soft toothbrush. C) Review the side effect of anticoagulants. D) Obtain stool specimen for guaiac.

D) Obtain stool specimen for guaiac Collecting specimens is a task that can be delegated to UAPs.

Review the incident involving the client's IV pump and hematuria. What specific information resulting from this event should be included in the client's incident report? (Select all that apply. One, some, or all options may be correct.) A) Day nurse received prescription to decrease Heparin infusion to 30 mL/hour. B) Nurse took action and stopped infusion. C) Oncoming nurse is named as witness and writes incident report. D) Oncoming nurse observes IV pump infusing at 50mL/hour. E) HCP contacted and prescribed STAT APTT and protamine sulfate. F) All the above

F) All the above

The nurse completes preparation of the initial heparin infusion and prior to administering takes which of the following actions? (Select all that apply. One, some, or all options may be correct.) A) Assesses client for allergies. B) Identifies client with two forms of identification. C) Ensure the client's IV access is intact and patent. D) Verifies baseline coagulation studies have been drawn. E) Initiates two nurses to check calculation accuracy. F) All the above

F) All the above