Clotting

The nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of:

Erythrocytes

A nurse is caring for several postoperative clients who had abdominal surgery. What independent nursing intervention can help prevent the development of thrombophlebitis?

Helping the client to perform in-bed exercises.

The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding?

Joints

A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply.

Eggs Liver Cheese

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?

Activated partial thromboplastin time (APTT) is two times the control value

A health care provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?

Ask the health care provider if an elastic bandage can be used in place of the stockings.

A client undergoes cardiac catheterization via the femoral artery. What is the most important nursing action after the procedure?

Assess the groin for bleeding

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition?

Clotting factor deficiency

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position?

Helps stop bleeding if any should occur

The laboratory international normalized ratio (INR) results of a client receiving warfarin (Coumadin) have been variable. The nurse interviews the client to determine factors contributing to the problem. Which is most important for the nurse to identify?

Adherence to the prescribed drug regimen

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?

An activated partial thromboplastin (APTT) twice the usual value

A client with a history of thrombophlebitis and varicosities is to have a herniorrhaphy for an incarcerated hernia. What primary nursing action should be implemented postoperatively considering the client's medical history?

Encourage the client to turn often and to exercise the legs regularly

A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over one hour for a client experiencing a myocardial infarction. The nursing priority that is specific to this medication is the assessment of the client's:

Intravenous insertion site

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, AquaMEPHYTON) 1 mg. The nurse explains to the parents that this vitamin is administered to:

Promote clotting of the blood.

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube?

Hyperoxygenate with 100% oxygen before and after suctioning.

A client is admitted to the hospital with signs and symptoms of obstruction of the common bile duct. Laboratory test results indicate prolonged bleeding and clotting times. What can the nurse conclude these test results indicate?

Vitamin K is not being absorbed

While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

Hemolytic

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching?

I'll use a straight razor when I start shaving."

A child has been found to have classic hemophilia. A nurse teaches the child's parents how to administer the plasma component factor VIII through a venous port. It is to be given three times a week. When should the parents administer this therapy?

In the morning on scheduled days

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?

Increased blood viscosity

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?" The nurse explains that the primary purpose of early ambulation is to:

Keep blood from pooling in the legs to prevent clots

When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. What is the priority nursing action?

Notify the health care provider because some herbs can cause hemorrhage

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. When describing the purpose of this drug to the client, the nurse explains that it:

Prevents extension of the clot

A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent?

Pulmonary embolism

After a suprapubic prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. The nurse recalls that this can be achieved best by increasing the:

Velocity of the venous return

A client is taking warfarin (Coumadin). The nurse recalls that the antidote for this medication is:

Vitamin K

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first?

Assess the catheterization site

The nurse providing immediate postoperative care to a client who had an abdominoperineal resection should assess for which clinical indicator of complications?

Bloody drainage on the abdominal and rectal dressings

A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." The nurse's initial response should be to:

Discuss the client's concerns

Immediately after a subtotal gastrectomy, a client is admitted to the postanesthesia care unit (PACU). The nurse irrigates the nasogastric tube and observes small blood clots in the return. What is the next best nursing intervention?

Document this expected response.

A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement?

Donning sterile gloves and applying direct pressure, using sterile gauze