Anticoagulant, Antiplatelet, & Thrombolytic Drugs

A patient with nonvalvular atrial fibrillation is to be discharged on dabigatran etexilate. Which statement should the nurse include in the discharge teaching?

"The medication must be stored in the manufacturer-supplied bottle."- "Once a new bottle is opened, the capsules maintain efficacy for 90 days." "If you have difficulty swallowing the capsule, you can open it and mix it with food." "You will need to learn how to give yourself a subcutaneous injection in your abdomen." Dabigatran etexilate is unstable, especially when exposed to moisture, and should be stored in the manufacturer-supplied bottle, which has a desiccant cap. Current labeling of the pill bottle indicates that once the bottle is opened, the pills should be used within 30 days. However, recent evidence indicates that they maintain efficacy for 4 months, provided they have been stored in the original container. Capsules should be swallowed intact, because chewing, crushing, or opening enhances absorption by 75% and increases the risk of bleeding. The medication is administered orally, not subcutaneously.

The nurse is teaching a patient about therapy with anticoagulants. What is essential information to include in the teaching plan?

Anticoagulants dissolve clots. Anticoagulants alter platelet function. Anticoagulants prevent clots from forming.- Anticoagulants interfere with drug metabolism. The patient needs to understand that anticoagulants will prevent new clots from forming but will not dissolve clots that are already formed. Anticoagulants inhibit clotting by acting on clotting factors and do not alter platelets or drug metabolism.

A patient who was admitted with deep vein thrombophlebitis is complaining of difficulty breathing and chest pain. What is the most likely cause of these symptoms?

Anxiety Medication reaction Embolus to the lungs- Fatigue from the extra work of walking with pain A thrombus can become an embolus and travel to the lungs. This pulmonary embolus can cause chest pain and difficulty breathing. It is not likely that fatigue, anxiety, or a medication reaction would cause chest pain and dyspnea in this case.

The patient is receiving warfarin therapy, and the nurse finds the international normalized ratio (INR) to be 4.0. How will the nurse interpret this finding?

The level is within the expected target therapeutic level of anticoagulation. The level is outside the expected target therapeutic level of anticoagulation: it is too low. The level is outside the expected target therapeutic level of anticoagulation: it is too high.- The level cannot be interpreted without knowing the prothrombin time and the activated partial thromboplastin time (aPTT) value. Target levels of the INR typically range from 2 to 3 with an average of 2.5; the average may increase to 3.0 for individuals taking warfarin for treatment of recurring systemic clots or emboli or those who have mechanical heart valves. The aPTT value is monitored with heparin, not warfarin.

The nurse is screening a patient for candidacy for treatment with fondaparinux. The nurse reviews the patient's laboratory test results and finds a creatinine clearance of 20 mL/min and a body weight of 48 kg. How will the nurse interpret these findings?

The patient is not a candidate for treatment with the medication based only on an insufficient creatinine clearance. The patient is a candidate for treatment with the medication based on a sufficient creatinine clearance and adequate body weight. The patient is a candidate for treatment with the medication based on sufficient creatinine clearance and after body weight attains an adequate level. The patient is not a candidate for treatment with the medication based on both an insufficient creatinine clearance and an inadequate body weight.- Fondaparinux is contraindicated with known allergy or in patients with a creatinine clearance less than 30 mL/min or a body weight of less than 50 kg; the patient is not a candidate for therapy.

Which instruction about clopidogrel should the nurse include in the discharge teaching for a patient who has received a drug-eluting coronary stent?

"Constipation is a common side effect of clopidogrel, so take a stool softener daily." "If you see blood in your urine or black stools, stop the clopidogrel immediately." "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity."- "Keep the amounts of foods containing vitamin K, such as mayonnaise, canola and soybean oil, and green, leafy vegetables, consistent in your diet." Patients taking clopidogrel should consult their healthcare provider before using over-the-counter (OTC) medications for gastric acidity. Proton pump inhibitors, such as omeprazole, and CYP2C1 inhibitors, such as cimetidine, can be purchased OTC to treat heartburn but can reduce the antiplatelet effects of clopidogrel. Diarrhea (5% incidence), not constipation, is a side effect of clopidogrel. Patients should immediately contact their healthcare provider if signs of bleeding occur, such as bloody urine, stool, or emesis. The drug should not be stopped until the prescriber advises it, because this could lead to coronary stent restenosis. Consistency of vitamin K intake is indicated while taking warfarin.

A patient with deep vein thrombosis receiving an intravenous heparin infusion asks the nurse how this medication works. What is the nurse's best response?

"Heparin converts plasminogen to plasmin, which in turn dissolves the clot matrix" "Heparin suppresses coagulation by helping antithrombin perform its natural functions."- "Heparin prevents activation of vitamin K and thus blocks synthesis of some clotting factors." "Heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels." Heparin is an anticoagulant that works by helping antithrombin inactivate thrombin and factor Xa, reducing the production of fibrin and thus decreasing the formation of clots. Thrombolytics (e.g., alteplase) dissolve existing clots. Blocking vitamin k-dependent clotting factors occurs with warfarin, not heparin. Platelet aggregation is blocked with antiplatelets such as aspirin, not with anticoagulants such as heparin.

The nurse is administering tenecteplase therapy to a patient experiencing an acute myocardial infarction. What will the nurse teach the patient about this therapy?

"This therapy will quickly decrease your pain." "This therapy will prevent new clots from forming." "This therapy will reverse damage from the infarction." "This therapy will dissolve the clot that caused the heart attack."- Tenecteplase is a thrombolytic drug that is given to dissolve existing clots. This drug is used when a blood clot in a coronary artery causes a myocardial infarction. The other statements are not correct. The therapy will not reverse damage, decrease pain response quickly, or prevent new clots from forming.

Which needle length and gauge should the nurse choose to administer subcutaneous heparin?

1½ inch; 20 gauge ⅝ inch; 25 gauge- 1½ inch; 18 gauge 1 inch; 26 gauge Heparin should be administered subcutaneously into the fatty layer of the abdomen with a ½- to ⅝-inch needle, 25 or 26 gauge. The other options have needle sizes that are larger, which would cause unnecessary discomfort and potential bruising and hematoma formation.

A patient has overdosed on warfarin. Which substance will the nurse administer to reverse the effect of warfarin?

Aspirin Calcium Potassium Phytonadione- The administration of phytonadione will help to reverse the action of warfarin. Coumadin interferes with vitamin K-dependent clotting factors. Administration of phytonadione will reverse this action. Aspirin will worsen the risk of bleeding in the setting of warfarin overdose and should be avoided. Calcium and potassium will have no effect on the warfarin overdose.

A bleeding patient receiving warfarin has an international normalized ratio (INR) of 6. What is the nurse's best course of action?

Administer phytonadione.- Stop the intravenous drip. Wait for the INR to decrease. Administer protamine sulfate. The nurse should administer phytonadione to the bleeding patient who is on warfarin and has an extremely elevated INR. This medication will block the vitamin K-dependent clotting factors. Increasing vitamin K can hasten the return to normal coagulation. Warfarin is given orally, not intravenously. Protamine sulfate is an antidote to heparin therapy, not warfarin.

The patient is receiving anticoagulant therapy. The international normalized ratio (INR) value for the patient today is 1.5. In response to this, the nurse could anticipate the healthcare provider placing which order?

Administer protamine sulfate. Increase the heparin drip rate. Hold the next dose of warfarin. Administer an additional dose of warfarin.- A therapeutic INR is 2 to 3.5. The patient needs more warfarin to reach a therapeutic level. It should not be held because that would increase the risk of clotting. Heparin is not ordered; that would be indicated by monitoring the activated partial thromboplastin time, not prothrombin time and INR. Protamine sulfate is the antidote for heparin overdose.

The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin?

Discolored urine- Heart rate of 60 beats/min Respiratory rate 14 breaths/min Blood pressure of 160/88 mm Hg The primary and most serious adverse effect of heparin is bleeding. Bleeding can occur from any site and may be manifested in various ways, including cloudy or discolored urine, reduced blood pressure, increased heart rate, bruises, petechiae, hematomas, red or black stools, pelvic pain, headache, and lumbar pain. Heart rate, blood pressure, and respiratory rate are not concerning related to the adverse effects of heparin.

The patient is being treated with a continuous intravenous (IV) infusion of heparin. What is the nurse's highest priority?

Ensure that protamine sulfate is readily available at all times.- Ensure that the patient's laboratory values are monitored correctly. Ensure that a loading dose was initially administered when treatment began. Ensure that the patient is taught dietary restrictions while on the medication. Protamine sulfate must be kept readily available because it is the antidote for an overdose of heparin. Although it is important to monitor the patient's laboratory values, this is not the priority. Teaching about limiting foods high in vitamin K is appropriate for warfarin, not heparin. Administering a loading dose before beginning the maintenance IV dose may not always occur.

The nurse is caring for a patient who takes warfarin for prevention of deep vein thrombosis. The patient has an international normalized ratio (INR) of 1.2. How should the nurse interpret this finding?

INR is too high; vitamin K may be needed. INR is within normal limits; no action is indicated. INR is too low; the dose may need to be increased.- INR is too high; intravenous protamine may be needed. An INR in the range of 2 to 3 is considered the therapeutic level for warfarin therapy; however, it may take several days to obtain peak effects. For a level of 1.2, the nurse should contact the healthcare provider, who will determine whether a dose adjustment is needed. Reversal with vitamin K would occur if the INR is greater than 8 or the patient is actively bleeding. Protamine sulfate reverses heparin, not warfarin.

The patient is scheduled to receive argatroban. Which is the correct route by which to administer the drug?

Intradermal Intravenous- Intramuscular Subcutaneous Argatroban is given only by the intravenous route. All other route options are not approved for administering argatroban.

Which statement is accurate for enoxaparin?

It equally reduces the activity of thrombin and factor Xa. It has selective inhibition of factor Xa and no effect on thrombin. It reduces the activity of factor Xa more than the activity of thrombin.- It has a lower bioavailability and shorter half-life than unfractionated heparin. Enoxaparin acts primarily on factor Xa and also, but to a lesser degree, on thrombin. Unfractionated heparin equally reduces the action of thrombin and factor Xa. Fondaparinux causes selective inhibition of factor Xa. Low-molecular-weight heparins, such as enoxaparin, have greater bioavailability and a longer half-life than unfractionated heparin.

The patient has been placed on aspirin as an antiplatelet drug. Which side effect is the patient most likely to experience?

Itching Edema Nausea- Chest pain Nausea accompanied by vomiting is an expected side effect of treatment with aspirin. Chest pain, edema, and itching are side effects that are more likely to be seen with the use of clopidogrel.

The patient is being treated with dabigatran and opens a new bottle of the medication on July 1. The nurse will instruct the patient to discard any unused medication by which date?

July 31- October 1 August 29 September 15 The patient who is being treated with dabigatran should use all of the medication in the bottle within 30 days of opening the bottle, although studies are showing efficacy for up to 4 months. After 60 days, the medication loses effectiveness.

Which nursing intervention is essential for a patient experiencing myocardial infarction who is receiving alteplase?

Monitor liver enzymes. Assess for dysrhythmias.- Administer prescribed vitamin K if bruising is observed. Stop the medication if the blood pressure drops below 110 systolic. Alteplase can cause bleeding as well as dysrhythmias. Reperfusion dysrhythmias are commonly seen after the return of blood flow to the myocardium. Alteplase does not directly affect liver enzymes. Vitamin K will not reverse the effects of alteplase. Vital sign changes can alert the nurse to complications; however, a blood pressure below 110 systolic is not, in itself, cause for alarm.

The nurse is monitoring a patient receiving reteplase therapy. Which assessment finding requires the most immediate action?

Nausea Change in mental status- Bruising on the upper arm A small amount of blood leaking around the intravenous catheter A change in mental status could indicate an intracranial bleed and should be investigated immediately. The other findings will need to be further assessed; however, they are not as high a priority as the change in mental status.

A patient diagnosed with a pulmonary embolism is receiving a continuous heparin infusion at 1000 units/hr. The nurse will immediately notify the healthcare provider of which findings? Select all that apply.

Nosebleeds- aPTT of 40 seconds- aPTT of 100 seconds- Platelet count of 300,000/µL Activated partial thromboplastin time (aPTT) of 65 seconds Measurement of the aPTT is essential to determine whether the heparin infusion is having the desired effect. If the normal value of the aPTT is 40 seconds, the goal is to achieve a therapeutic range of a factor of 1.5 to 2 (60 to 80 seconds). Because 40 seconds is too short (increases the risk for clotting) and 100 seconds is too long (increases the risk for bleeding), the physician requires notification for adjustment of the infusion rate. Evidence of bleeding, such as nosebleeds, hematuria, and red or tarry stools, warrant a call to the physician. An aPTT of 65 seconds indicates that a therapeutic effect has been achieved, and a platelet count of 300,000/µL is within normal limits, indicating no evidence of thrombocytopenia.

The nurse is caring for a newly admitted patient who will begin heparin therapy. While documenting the patient's history, the nurse notes that the patient is currently undergoing treatment with enoxaparin. What is the nurse's highest priority?

Notify the provider that the patient is at risk for an allergic reaction. Notify the provider that the patient should not be started on heparin.- Notify the provider that the dosage of heparin will need to be increased. Notify the provider that the dosage of heparin will need to be decreased. A potential medication error is to give heparin in combination with enoxaparin related to potentiative effects between the two medications, that would further increase the risk of bleeding.

The laboratory calls to report a drop in the platelet count to 90,000/mm 3 for a patient receiving heparin for the treatment of postoperative deep vein thrombosis. Which action by the nurse is the most appropriate?

Obtain vitamin K and prepare to administer it by intramuscular injection. Notify the healthcare provider to discuss the reduction or withdrawal of heparin.- Observe the patient and monitor the activated partial thromboplastin time (aPTT) as indicated. Call the healthcare provider to discuss increasing the heparin dose to achieve a therapeutic level. The nurse should notify the healthcare provider to discuss the reduction or withdrawal of heparin. Heparin-induced thrombocytopenia (HIT) is a potential immune-mediated adverse effect of heparin infusions that can prove fatal. HIT is suspected when the platelet counts fall significantly. A platelet count below 100,000/mm 3 would warrant discontinuation of the heparin. Vitamin k is used for reversal of warfarin, not heparin. Increasing the dose would worsen the platelet count. Monitoring the aPTT will not decrease the risks associated with thrombocytopenia.

The nurse is reviewing laboratory data before initiating a patient's heparin infusion. Which finding requires immediate action?

Platelets 95,000/mm 3- Potassium 3.5 mEq/L International normalized ratio (INR) of 1 Activated partial thromboplastin time (aPTT) of 37 seconds A platelet count of less than 100,000/mm 3 indicates thrombocytopenia. This significantly increases the patient's risk of bleeding. Heparin should be withheld. In addition, thrombocytopenia at the onset of heparin therapy confounds the ability of the healthcare team to detect heparin-induced thrombocytopenia. The INR, aPTT, and potassium levels are all within normal limits.

A patient is receiving a continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor? Select all that apply.

Platelets- Vitamin K Prothrombin time (PT) International normalized ratio (INR) Activated partial thromboplastin time (aPTT)- To reduce the risk of heparin-induced thrombocytopenia, platelet counts should be monitored. Heparin therapy is monitored by measuring aPTT. Warfarin therapy is monitored by measuring PT and results are expressed as an INR. Vitamin K is not monitored for a heparin infusion.

A nurse is preparing to administer enoxaparin sodium to a patient for prevention of deep vein thrombosis. Which is an essential nursing intervention?

Rub the administration site after injecting. Use the Z-track method to inject the medication. Administer the medication into subcutaneous tissue of the abdomen.- Draw up the medication in a syringe with a 22-gauge, 1½-inch needle. Enoxaparin is a low-molecular-weight heparin that is administered subcutaneously. The site should not be rubbed after injection, and the Z-track method should never be used to administer enoxaparin sodium. The use of a 22-gauge, 1½-inch needle is more appropriate for administration of an intramuscular injection.

A patient has been receiving intravenous heparin. The nurse notes that today's activated partial thromboplastin time (aPTT) result is elevated. What is the nurse's best action?

Stop the medication. Increase the dose of heparin. Notify the healthcare provider immediately. Monitor the patient and check the therapeutic range. An elevated aPTT would be expected in a patient who is receiving heparin. The nurse should continue to monitor the patient. The medication should not be stopped because this is a therapeutic effect. The healthcare provider would not have to be notified unless the aPTT is above the therapeutic range. The dose of heparin would not have to be increased. The nurse does have to check the therapeutic range expected for the therapy.

The nurse is caring for a patient who is scheduled to begin warfarin treatment and is currently being treated with amiodarone. Based on this information, the nurse anticipates which change will be made to the medication regimen?

The dosage of the warfarin will be increased. The dosage of the warfarin will be decreased.- The dosage of the amiodarone will be increased. The dosage of the amiodarone will be decreased. When amiodarone is given along with warfarin therapy, it is recommended that the warfarin dose be cut in half because amiodarone increases the effectiveness of warfarin. Increasing the dose of warfarin would increase the risk of bleeding. The dose of amiodarone should not be altered.

The nurse is caring for a patient who is being treated with dabigatran. The nurse is monitoring the patient's laboratory test results and notes that the creatinine clearance is 25 mL/min. Based on this information, the nurse anticipates which change to the medication regimen?

The medication will be stopped completely. The dose of the medication will be increased. The dose of the medication will be decreased.- The dose of the medication will be unchanged. The normal dose of dabigatran is 150 mg twice daily, but it must be reduced to 75 mg daily if the creatinine clearance is less than 30 mL/min. There is no reason to stop the medication completely as long as it is dose adjusted for the renal function.

The nurse is caring for a patient who is being treated with fondaparinux and notes a platelet count of 80,000/mm 3. Based on this information, the nurse anticipates which change to the medication regimen?

The medication will be stopped completely.- The dose of the medication will be increased. The dose of the medication will be decreased. The dose of the medication will be unchanged. Fondaparinux should be stopped if the platelet count falls below 100,000 platelets per microliter. The medication should be stopped, not increased, decreased, or unchanged.

The nurse is preparing to administer an anticoagulant to a patient. Which action, if observed, is in error?

The nurse administers warfarin orally to a patient. The nurse administers dabigatran orally to a patient. The nurse administers heparin subcutaneously to a patient. The nurse administers enoxaparin intramuscularly to a patient.- The nurse should not administer an anticoagulant intramuscularly because this would cause a high risk of bleeding into the muscle and a large hematoma to form at the injection site. The other medications can be administered via the routes listed.

Which patient does the nurse anticipate will receive alteplase therapy?

The patient with peptic ulcer disease The patient with a gastrointestinal bleed The patient with severe chest pain for the past 2 hours- The patient with a local thrombosis from a peripheral intravenous line The best candidate for therapy with alteplase is the patient who complains of new-onset chest pain. It is likely the chest pain is caused by a clot in a coronary artery. Thrombolytic therapy could dissolve the clot and alleviate the myocardial ischemia and the pain. The patients with peptic ulcer disease and gastrointestinal bleeding would have an increased risk of bleeding with this therapy. The patient with a local thrombosis will not need treatment because the thrombosis is typically small and is reabsorbed with local therapy.

A patient who is receiving heparin therapy has bruises covering the abdomen as well as red-colored urine. What does the nurse need to assess?

Urine culture Platelet level- Ingestion of acetaminophen Over-the-counter medications The patient's platelet level should be assessed when he or she receives heparin and then develops bruises and blood in the urine. The patient may have type II heparin-induced thrombocytopenia. The patient's medication would need to be changed. Although over-the-counter medications may potentiate bleeding, they are not likely to cause these symptoms. Acetaminophen and urinary tract infections should not cause these symptoms. A urine culture is not indicated because that would be used to assess for infection, not bleeding.

A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg intravenous bolus of alteplase, a tissue plasminogen activator, followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse indicates the most serious adverse reaction to the medication?

Urticaria, itching, and flushing Potassium level of 5.5 mEq/L Blood pressure of 90/50 mm Hg Decreasing level of consciousness- The greatest risk with alteplase is bleeding, with intracranial bleeding being the greatest concern. A decreasing level of consciousness indicates intracranial bleeding. Alteplase does not cause an allergic reaction or hypotension. Thrombolytic agents, such as alteplase, do not typically cause an elevated potassium level. Urticaria, itching, and flushing may indicate an allergic reaction; however, the decreased level of consciousness would be more serious.

A patient admitted with deep vein thrombosis and subsequent pulmonary embolism (PE) requires immediate anticoagulation. Which medication would be appropriate for initial therapy for this patient who has a history of heparin-induced thrombocytopenia (HIT)?

Warfarin Argatroban- Eptifibatide Bivalirudin Argatroban is indicated for the treatment of thrombosis in patients with a history of HIT. Because this medication is given as an initial intravenous bolus followed by a continuous infusion, the desired effect of direct thrombin inhibition is achieved more quickly. Because of warfarin's delayed onset of effects, it is not useful in emergency situations, such as PE. Intravenous bivalirudin given in combination with aspirin helps prevent clot formation in patients undergoing coronary angioplasty. Eptifibatide, a glycoprotein IIb/IIIa receptor inhibitor, is an antiplatelet drug that is used short term to prevent ischemic events in patients who have acute coronary syndrome or who are undergoing percutaneous coronary intervention.