Passpoint Clotting

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client?

Bed rest with the affected extremity elevated

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?

Blood pressure

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: cerebral, cardiopulmonary, GI

A client recovering from an abdominal hysterectomy has pain in her right calf. What should the nurse do next?

Measure the circumference of both calves and note the difference.

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

Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg?

Pressure on the site and administration of the required clotting factor

The nurse is planning care for a client with acute myeloid leukemia (AML). What is an appropriate goal for this client?

Prevent hemorrhage

Which goal is most important when developing a long-term care plan for a child with hemophilia?

Prevent injury during each stage of development

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

Remove elastic stockings once per day and observe lower extremities.

The nurse is evaluating a client who received tissue plasminogen activator (t-PA) following a myocardial infarction (MI). What is the expected outcome of this drug?

Revascularize the blocked coronary artery

The nurse is preparing a client for an ileostomy. Two weeks before the surgery, what should the nurse instruct the client to do?

Stop taking drugs that will interfere with clotting.

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?

The client's right lower leg is red, swollen, and warm to touch.

The nurse is planning care for several clients. Which client does the nurse prioritize as being at highest risk for developing a pulmonary embolism?

a client who has fractures of the pelvis and right femur

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy

Which assessment finding supports the administration of protamine sulfate?

aPTT 3.5-5 times normal

A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which nursing intervention takes priority?

applying pressure to the puncture site for a full 10 minutes

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?

bleeding disorder

A nurse is caring for a client with deep vein thrombosis. Which change in assessment findings would the nurse be alert for related to the condition?

chest pain and dyspnea

Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene?

cleaning the teeth with a toothbrush

The nurse is beginning a shift caring for a group of postpartum clients. Which client should the nurse see first?

client who reports she has pain in the left calf

When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, the nurse would anticipate administering intravenously which therapeutic agent if the client develops disseminated intravascular coagulation (DIC)?

fresh frozen platelets

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

massages the client's legs.

A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings?

platelet count of 80 x 103/mm3 (80 X 109/L)

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

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?

pulmonary embolism

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement?

"I'll try to lose weight by following a reduced-calorie, balanced diet."

A boy, age 2, is diagnosed with hemophilia. The nurse explains to the father how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of gene transmission?

"Our newborn daughter may be a carrier of the trait."

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?

"Vitamin K will help my baby's blood to clot properly."

A client with deep vein thrombosis has an I.V. infusion of heparin infusing at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters of solution should the nurse document as intake from this infusion for an 8-hour shift? Record your answer using a whole number.

240

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360

A health care provider prescribes intravenous heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction (MI). After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The health care provider orders the infusion to be increased to 800 units/hour. The nurse would set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.

8

A nurse reviews the care plan for an adolescent receiving chemotherapy for leukemia. The adolescent's platelet count is 50,000 μl. The client also has pneumonia. Which item in the care plan should the nurse revise?

Administer oxygen at a rate of 4 L/minute using a non-humidified nasal cannula.

What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Apply gentle pressure to the site with a sterile gauze pad.

A school-age client with hemophilia A has fallen and badly bruised his knee. Which action should the nurse do first to manage the client's hemarthrosis?

Apply pressure and immobilize the joint.

A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. What should the nurse do first?

Assess the oxygen saturation.

A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy?

Dissolved emboli

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride?

Do ankle pumps

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1,000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. What should the nurse do first?

Don gloves and apply direct pressure over the site.

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom?

Dyspnea

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Elevate the affected part

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees.

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do?

Elevate the right knee.

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.

The nurse is planning discharge teaching for a client who will continue taking the prescribed warfarin at home. What early symptoms of occult blood loss should the nurse teach the client?

Increasing fatigue and shortness of breath.

What information should the nurse provide to the client who is receiving warfarin?

International Normalized Ratio (INR) is used to assess effectiveness.

The nurse reviews the morning laboratory results from a client admitted with a deep vein thrombosis. The client is receiving intravenous heparin. Based on the client's current laboratory values, what should the nurse do?

Maintain the current rate of the heparin infusion.

After the administration of t-PA, the assessment priority is to:

Observe the client for chest pain.

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy?

Partial thromboplastin time, 1.5 to 2.5 times the normal control.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately?

The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization.

A toddler has a temperature above 101°F (38.3°C). The healthcare provider orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of:

Thrombocytopenia

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do?

Withhold the dose of the medication and contact the HCP.

Which client is at greatest risk for Buerger's disease?

a 29-year-old male with a 14-year history of cigarette smoking.

Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy?

activated partial thromboplastin time (APTT)

A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?

depot medroxyprogesterone acetate injection

The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)?

elevated PT/INR

The nurse is caring for a client 24 hours postpartum from a normal, vaginal birth. For which client reported symptom will the nurse prioritize further assessment?

feeling pain and warmth behind left knee

A client who has been recently extubated has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP?

hemoglobin and hematocrit

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms?

hypertension

A client with cancer is receiving radiation therapy and develops thrombocytopenia. What is the priority nursing goal to prevent which effect of thrombocytopenia for this client?

injury related to the decreased platelet count

A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. What should the nurse include in the plan of care for this client?

monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (PT/INR)

Which signs and symptoms of leukemia would lead the nurse to suspect the client has thrombocytopenia? Select all that apply.

petechiae epistaxis

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy?

prothrombin time (PT)

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to

sit upright, leaning slightly forward.

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?

tachycardia

A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first?

the client with unilateral leg swelling who reports anxiety and shortness of breath

A client has had a total abdominal hysterectomy. The nurse should specifically assess the client for which potential complication related to this surgery?

thrombophlebitis

Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for:

thrombophlebitis.

The primary goal for the client with Buerger's disease is to prevent:

thrombus formation.

A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used

to provide long-term access to central veins.

The nurse is providing dietary instructions for a client who is taking warfarin. Which menu choice would be most appropriate for this client?

tuna fish sandwich, French fries, and a baked apple

The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care? Select all that apply.

turning every 2 hours passive and active range-of-motion exercises use of thromboembolic disease support (TED) hose