Anticoagulant, Antiplatelet & Thrombolytic Drugs

Which types of clots are thrombolytic events? (SATA) a. Scab b. Thrombus c. Embolus d. Clotted intravenous catheter e. Fat embolus

B, C, E ~ Thrombolytic events are dangerous clots. They include thrombus and embolus. These clots are dangerous because of the risk of blocked blood flow.

Which blood component forms the initial plug that helps stop bleeding? a. Fibrin b. Platelets c. Neutrophils d. Eosinophils

B ~ While fibrin creates threads that make the plasma sticky and able to clot, it is platelets that clump together to create the initial plug that helps to stop bleeding. Neutrophils and eosinophils are types of white blood cells that help the body fight off infection.

Which factors are absolute contraindications for thrombolytic therapy? (SATA) a. Active peptic ulcer disease b. Active internal bleeding c. Recent head trauma d. Endocarditis e. Suspected aortic aneurysm f. Surgery within the last 10 days

B, C, E ~ An accurate patient history is essential before giving a thrombolytic drug. Absolute contraindications include active internal bleeding, known allergy to streptokinase products, recent head trauma, known bleeding disorders, suspected aortic dissection, increased blood pressure of 200/120 mm Hg, pregnancy or recent delivery, cerebrovascular processes (e.g., recent stroke, recent spinal or cerebral surgery, cranial neoplasm, and prolonged cardiopulmonary resuscitation). Active peptic ulcer disease, endocarditis, and surgery within the past 10 days are relative contraindications for this therapy. The prescriber weighs the pros and cons of the treatment before making a decision to use the drug.

Which actions are performed by the nurse when giving a subcutaneous injection of low-molecular weight heparin? (Select all that apply.) a. Position the patient lying down. b. Expel the air bubble before injection. c. Insert the needle into a skin fold held between the thumb and forefinger. d. Release the skin fold then inject the drug. e. Rub the injection site to avoid bruising.

A, C ~ Low molecular weight heparin is given by deep subcutaneous injection with the patient lying down. The needle should be inserted into a skin fold held between the thumb and the forefinger. To avoid losing any of the drug, the nurse should not expel the air bubble before injection. The skin fold should be held until the injection is completed. The nurse should not rub the injection site.

A patient is being discharged on enoxaparin (Lovenox). Which statement does the nurse include in the discharge teaching plan? a. An advantage of this drug is that labs do not need to be drawn to guide therapy. b. Follow-up lab work must be drawn every 2 to 6 months. c. Enoxaparin is given intramuscularly twice a day. d. The purpose of this drug is to dissolve clots.

A ~ A major advantage of using low-molecular-weight heparins such as enoxaparin is that patients are not required to have laboratory work done to guide their therapy. The drug is given two times daily subcutaneously. Its purpose is to prevent venous thromboembolic events and pulmonary embolism.

A patient with a vein thromboembolism is to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is the nurses best action? a. Administer the drugs as prescribed. b. Remind the prescriber that two anticoagulants should not be administered concurrently. c. Hold the dose of warfarin until the patients activated partial thromboplastin time is the same as the control value. d. Monitor the patient for clinical manifestations of internal or external bleeding at least every 2 hours.

A ~ Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the patient is still receiving heparin.

The client is being treated with warfarin sodium as well as a diuretic. The nurse anticipates that the interaction of the two drugs will produce a(n) _____ effect from the _____. a. increased; warfarin sodium b. decreased; warfarin sodium c. increased; diuretic d. decreased; diuretic

A ~ The interaction of warfarin sodium and a diuretic will produce an increased effect from the warfarin sodium.

The client who is most likely to be ordered lowmolecular-weight heparin would be the client who is considered to be at high risk to develop: a. venous thrombosis. b. arterial embolism. c. thrombocytopenia. d. leukopenia.

A ~ These heparin-like medications prevent clot formation.

A patient is taking warfarin (Coumadin) daily to prevent blood clots from forming in deep veins. Which statement made by the patient indicates that more teaching is needed about this therapy? a. I have been eating more salads and other green, leafy vegetables to prevent constipation. b. I have been using acetaminophen (Tylenol) instead of aspirin for pain. c. Instead of a safety razor, I have been using an electric shaver. d. On hot days, I make sure to drink at least two quarts of water.

A ~ Vitamin K is present in green, leafy vegetables and increases blood clotting by increasing the synthesis of specific clotting factors in the liver. Warfarin is a vitamin K antagonist. Ingestion of large amounts of vitamin K can counteract the therapeutic effects of warfarin.

A client receiving warfarin (Coumadin) is noted to have significant bleeding from the gums while on therapy. The physician orders an antidote. If excess bleeding occurs because of warfarin accumulation in the body, what is the antidote? a. Vitamin K b. Vitamin E c. Naloxone (Narcan) d. Protamine sulfate

A ~ Vitamin K is the antidote for warfarin.

A patient has been discontinued from warfarin (Coumadin) therapy for 3 weeks. Which laboratory test indicates to the nurse that all effects of the warfarin have been eliminated? a. International normalized ratio (INR) of 0.9 b. Red blood cell count of 5 million/mm3 c. Hemoglobin of 16 g/dL d. Hematocrit of 42%

A ~ Warfarin therapy increases the INR, which normally ranges between 0.7 and 1.8. Therapeutic warfarin levels should maintain the INR between 2.0 and 3.0. When the effects of warfarin are no longer present, the INR returns to normal levels. Warfarin therapy does not affect white blood cell count, serum ferritin levels, or the reticulocyte count.

A patient in the emergency department developed stroke symptoms one hour ago. Which type of drug will the nurse expect to administer to resolve this problem? a. Thrombolytic b. Thrombin inhibitor c. Antiplatelet drug d. Clotting factor synthesis inhibitor

A ~ When an ischemic stroke occurs there is an existing clot in an artery in the brain. To resolve this problem early after symptoms develop, a thrombolytic drug (clot buster) is prescribed. These drugs must be administered within 3 hours of the onset of symptoms for stroke. Thrombin inhibitors and clotting factor synthesis inhibitors prevent new clots from forming and existing clots from getting larger. Antiplatelet drugs prevent platelets from clumping together (aggregating).

The nurse prepares to administer an intramuscular injection to a patient who is on anticoagulation therapy. Which techniques does the nurse perform to prevent excessive bleeding? (Select all that apply.) a. Using the smallest possible injection needle b. Injecting the drug slowly, over at least a 60-second period c. Applying pressure to the site for at least 5 minutes after the injection d. Ensuring that the needle is placed within a previous injection puncture site e. Cleansing the skin at the injection site for at least 30 seconds before the injection f. Applying warm compresses to the site for at least 15 minutes after the injection

A, C ~ Using the smallest needle possible results in less tissue trauma and less risk for bleeding. Applying pressure over the injection site for at least 5 minutes after administration compresses surrounding blood vessels and reduces the risk for bleeding. Injecting the drug slowly can increase the risk for bleeding by traumatizing tissues longer. Placing the needle in the same puncture site as a previous injection can increase the risk for bleeding by enlarging the hole and not allowing the previously damaged tissue to heal. Cleansing the skin can reduce infection risk but does nothing to reduce bleeding risk. Applying warm compresses is more likely to increase bleeding risk by dilating blood vessels in the area. Cold compresses or ice applied to the area would reduce bleeding risk.

A patient who received the thrombolytic drug alteplace (Activase) asks the nurse why continuous heparin is now infusing intravenously. What is the nurses best response? a. There may be additional clots in your body and we want to be sure they are all dissolved. b. Once the clot is dissolved, heparin is given continuously to prevent any new clots from forming. c. The heparin finishes the job of dissolving the clot that the alteplace started. d. Heparin is infused continuously in case we need to give additional dosages of alteplase.

B ~ After thrombolytic therapy to dissolve an existing clot, anticoagulation with heparin prevents the formation of new clots.

A patient asks the nurse why an anticoagulant has been prescribed. What is the nurses best response? a. It will dissolve any clots in your blood vessels. b. It will prevent any new clots from forming. c. It will prevent a clot from migrating. d. It will thin your blood.

B ~ Anticoagulant drugs are sometimes called blood thinners but they do not thin the blood, prevent clots from migrating, or dissolve existing clots. These drugs prevent new clots from forming and prevent existing clots from becoming larger.

How are anticoagulant drugs and thrombolytic drugs different? a. There is no difference; they both have the same actions. b. Anticoagulants prevent clots from forming whereas thrombolytics can dissolve clots that have already formed. c. Thrombolytics must be administered intravenously while all anticoagulants are administered as oral agents. d. Anticoagulants prevent clots by actually thinning the blood whereas thrombolytics reduce platelet aggregation and do not affect blood thickness.

B ~ Both thrombolytics and anticoagulants disrupt steps in clot formation. However, anticoagulants have no effect on clots that have already formed. Only thrombolytics can dissolve an existing clot. Neither drug causes a thinning of the blood. Blood viscosity (thickness or specific gravity) remain the same when a person receives either class of drug.

A patient prescribed subcutaneous heparin tells the nurse that her menstrual bleeding is heavier than usual. What is the nurses best response? a. I will hold the drug and notify your prescriber. b. This is a fairly common and expected side effect of the drug. c. Heavy bleeding is a concern because you might become anemic. d. I will have to give you a shot of protamine sulfate to reverse the drugs action.

B ~ Common side effects of anticoagulant therapy include increased risk for bleeding. Bleeding from the gums, oozing from cuts or wounds, nosebleeds, and heavier than usual menstrual bleeding can occur.

Why are erythropoiesis-stimulating agents (ESAs) prescribed for patients with chronic kidney disease? a. To protect the kidney from further hypoxic damage during anemia episodes b. To improve blood cell counts and reduce the need for blood transfusions c. To prevent vein thromboembolism during periods of dehydration d. To reduce the risk of uric acid precipitation and renal failure

B ~ ESAs stimulate the bone marrow to produce more red blood cells. The person with chronic kidney disease has chronic anemia because the damaged kidney no longer produces natural erythropoietin. The use of ESAs in patients with chronic kidney disease improves red blood cell counts and reduces anemia to such an extent that blood transfusions often are no longer needed.

A patient is receiving oprelvekin (Neumega) subcutaneously daily. Which laboratory value indicates to the nurse that the therapy is effective? a. Hemoglobin 12 g/dL b. Platelet level 55,000/mm3 c. Red blood cells 4.5 million/mm3 d. International normalized ratio (INR) 1.0

B ~ Oprelvekin is a thrombopoietic colony stimulating factor that increases production of platelets. It is only used until the patients platelet level reaches 50,000/mm3.

A client is being treated with warfarin (Coumadin). The highest priority nursing intervention before administration of the medication is to check the: a. PTT and APTT. b. PT and INR. c. most current CBC. d. most current platelet count.

B ~ PT and INR are the tests monitored with warfarin.

A client is to receive a heparin injection. The highest priority nursing intervention before administration of the medication is to check the: a. PT and INR. b. PTT and APTT. c. CBC. d. platelet count.

B ~ PTT and APTT are the blood tests that assess bleeding times.

In planning care for a client receiving heparin, the nurse is aware that the dose is administered subcutaneously. What is the reason for using this route? a. Heparin is absorbed readily by the gastrointestinal mucosa and protected by the liver. b. Heparin is poorly absorbed by the gastrointestinal mucosa and destroyed by liver enzymes. c. The effective absorption of heparin can be hampered by food. d. The effective absorption of heparin is hampered by the stomachs inadequate blood flow.

B ~ Subcutaneous administration of heparin prevents poor absorption and eliminates destruction of heparin by the liver.

The client is being treated with heparin and also with nitroglycerin. The nurse anticipates that the interaction of the two drugs will produce which effect? a. Inadequate effect from the nitroglycerin b. Decreased effect from the heparin c. Toxic dose of the nitroglycerin d. Increased effect from the heparin

B ~ The interaction of heparin with nitroglycerin will most likely produce a decreased effect from the heparin.

A patient who has been prescribed continuous intravenous (IV) heparin asks the nurse why being weighed is necessary. What is the nurses best response? a. All patients are weighed upon admission to the hospital. b. IV heparin has been known to cause weight gain. c. The initial IV bolus of heparin is prescribed based on your weight. d. The rate of the heparin infusion is based on your weight.

C ~ Always get an accurate weight on a patient to be placed on continuous IV heparin because the initial bolus is based on weight. The rate of the infusion is based on aPTT results. IV heparin is not the cause of weight gain. While all patients are weighed on admission to the hospital, this response does not answer the patients question.

A patient prescribed an anticoagulant long-term engages in all of the following activities. Which activity does the nurse teach the patient to avoid? a. Golfing b. Bowling c. Jumping rope d. Walking 2 miles daily

C ~ Any person taking anticoagulants long-term must avoid activities that can traumatize tissue and lead to bleeding, such as contact sports (e.g., football, hockey), and activities that put extra weight and stress on the leg joints and spine (e.g., jumping rope, jogging, high impact exercise). Jumping rope can cause bleeding into the joints, especially the knee, which can lead to permanent damage.

A new nurse is listing the interventions he should employ when caring for a client on thrombolytic therapy. Which nursing intervention is inappropriate for the client during thrombolytic therapy? a. Monitor vital signs and reporting changes. b. Check for active bleeding for 24 hours after therapy. c. Inform the client that aspirin and NSAIDs may be taken for discomfort. d. Monitor electrocardiogram strips for cardiac dysrhythmias.

C ~ Aspirin or NSAIDs would increase the bleeding time further. ECGs may be done to assess for changes to the myocardial muscle.

The client is being treated with Plavix. He complains to the nurse of experiencing chest pain. The highest priority nursing intervention is to call the physician because the client is experiencing a(n): a. adverse reaction to the medication. b. myocardial infarction. c. expected side effect of the medication. d. anaphylactic reaction to the medication.

C ~ Chest pain is an expected side effect of treatment with Plavix.

The client has been ordered treatment with warfarin. She tells the nurse that she self-medicates with herbal remedies as much as possible. The highest priority teaching point that the nurse should give the client is the avoid the use of _____ while taking warfarin. a. ephedra and dill b. black cohosh and licorice c. garlic and ginkgo d. ginseng and green tea

C ~ Garlic and ginkgo interfere with the formation of platelet aggregations.

Which drug must always be available on a unit where heparin therapy is occurring? a. aspirin b. vitamin K c. protamine sulfate d. warfarin (Coumadin)

C ~ Protamine sulfate is the antidote to a heparin overdose. It should always be available wherever patients are receiving heparin.

The aPTT of a patient who is prescribed continuous intravenous (IV) heparin is two times the control value. What is the nurses best action? a. Increase the IV rate as ordered. b. Decrease the IV rate as ordered. c. Leave the rate unchanged. d. Stop the infusion and notify the prescriber.

C ~ The goal of continuous heparin therapy is to keep the aPTT within a therapeutic range of 1.5 to 2.5 times greater than the laboratory-established control value. Two times the control value is within this range. The prescriber should be notified, but the infusion rate, which is therapeutic, will not change at this time.

Which statement made by a client receiving (warfarin) Coumadin therapy indicates a need for further teaching? a. I shouldn't take aspirin while I'm on Coumadin. b. I will use a toothbrush with soft bristles. c. I will eat large quantities of green leafy vegetables. d. I will use an electric razor to avoid shaving cuts.

C ~ Vitamin K is an antagonist against warfarin, and green leafy vegetables are known sources of vitamin K.

Which statement by a patient who is prescribed heparin indicates to the nurse the need for additional teaching? a. Ill be sure to have my follow-up aPTT drawn when the prescriber tells me to. b. I will not take over-the-counter drugs that contain aspirin. c. I will get plenty of exercise playing soccer. d. Ill tell my prescriber if I have headaches.

C ~ While taking heparin, patients should avoid contact sports and other activities that may cause injury. Falls, blows to the body or head, headaches that wont go away, or other injuries should be reported to the prescriber right away.

The client has received an overdose of a thrombolytic drug. The nurse anticipates that he will be treated with: a. naloxone (Narcan). b. protamine sulfate. c. vitamin E. d. aminocaproic acid (Amicar).

D ~ Aminocaproic acid (Amicar) is the drug to have on hand in the event of hemorrhage as a result of thrombolytic drugs.

A client receiving clopidogrel (Plavix) has the following conditions as part of the health history. Which causes the greatest concern to the nurse? a. Asthma b. Glaucoma c. Allergy to shellfish d. Active peptic ulcer

D ~ An active peptic ulcer may bleed subsequent to use of this medication.

A patient coming to the clinic for a weekly infusion of darbepoetin alpha (Aranesp) has all of the following changes. For which change does the nurse hold the dose of the drug? a. Weight loss of five pounds b. Hemoglobin increase from 8 g/dL to 10 g/dL c. Blood potassium increase from 3.8 mEq/L to 4.8 mEq/L d. Blood pressure increase from 126/80 mm Hg to 148/92 mm Hg

D ~ Because these drugs increase blood cell production, the blood becomes more viscous (thicker). This effect raises blood pressure, increases clot formation, and slows blood movement through small vessels. This patient is hypertensive, so the next dose of darbepoetin can increase the pressure to dangerous levels and greatly increase the risk for stroke and heart attack. The drug should not be administered until the patients blood pressure is in the normal range.

Why should children not be prescribed aspirin or aspirin-containing products? a. There is more risk for bleeding in children than in adults. b. Aspirin products are more likely to cause GI upset in children. c. Children are more likely to experience allergic reactions to aspirin-containing products. d. Risk for Reyes syndrome, which effects brain and liver function, is increased in children.

D ~ Children who take aspirin or aspirin-containing products are at risk for Reyes syndrome, a rare but serious illness that affects brain and liver functions.

The client is being treated with warfarin sodium. She complains to the nurse of soreness in her mouth. The highest priority nursing intervention is to call the physician because the client is _____ the medication. a. beginning to hemorrhage from b. developing a clot from c. experiencing an expected side effect of d. experiencing an adverse reaction to

D ~ Mouth soreness would be indicative of stomatitis, an adverse reaction to the medication.

Which dietary teaching does the nurse include for a patient who is prescribed warfarin (Coumadin) on discharge? a. Weight loss diets such as the Atkins diet are OK while taking this drug. b. Be sure to eat lots of green leafy vegetables for extra vitamin K. c. Dietary changes do not affect the action of this drug. d. Drinking alcoholic beverages can change the action of warfarin.

D ~ Patients should be taught to maintain their current diet and not to adopt fad diets such as an all-vegetarian diet or the Atkins diet. Abrupt dietary changes can alter the INR test results. Foods rich in vitamin K may interfere with the action of warfarin (vitamin K is the antidote for warfarin). Alcohol can also interfere with the action of warfarin and patients should be instructed to discuss this with their prescriber before drinking.

A patient who has been receiving heparin subcutaneously for 3 weeks has all of the following laboratory blood test values. Which value does the nurse report immediately to the prescriber? a. Activated partial thromboplastin time 1.5 b. International normalized ratio (INR) 1.7 c. Red blood cells 4.2 million/mm3 d. Platelets 20,000/mm3

D ~ The normal range for platelets is 200,000 to 400,000/mm3. Platelets are needed for blood clotting. This patients platelet count is extremely low and he or she is at grave risk for severe bleeding. The low platelet count is an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin needs to be discontinued and the patient needs to receive platelet therapy before life-threatening hemorrhage occurs.

Which action does the nurse avoid after administering a thrombolytic drug? a. Administering IV drugs b. Using electric razors c. Providing a soft toothbrush d. Giving an intramuscular injection

D ~ Thrombolytic drugs dissolve existing clots, so there is a high risk for bleeding with any invasive procedures such as intramuscular injections. Administration of IV drugs through an already existing line is acceptable, but the nurse would not want to place a new line or discontinue an existing line. Use of electric razors and soft toothbrushes are safe with patients who have received a thrombolytic drug.

Why is warfarin (Coumadin) avoided during pregnancy? a. Warfarin can induce premature closure of the foramen ovale in the fetus. b. The fetal and newborn liver cannot metabolize warfarin and anemia results. c. The fetus and newborn are more likely to have allergic reactions to warfarin. d. Warfarin crosses the placenta and causes birth defects or hemorrhage in the fetus.

D ~ Warfarin is a pregnancy category D drug with a chemical composition the same as rat poison. It can cause birth defects and can reduce clotting in the fetus to such an extent that severe and fatal hemorrhage in the fetus is possible (especially brain hemorrhage).

Which condition occurs as a result of a thrombus developing in a coronary artery? a. Cerebrovascular accident b. Deep vein thrombosis c. Pulmonary embolus d. Myocardial infarction

D ~ When a thrombus develops in a coronary artery and blocks the blood supply to a part of the heart muscle, a heart attack (myocardial infarction) occurs. Cerebrovascular accident (stroke) occurs when a thrombus blocks an artery in the brain. Deep vein thrombosis occurs when a clot blocks a deep vein, such as a leg vein. Pulmonary embolus occurs when an embolus blocks blood flow in an artery in the lungs.