DVT/PE/Varicose Veins Practice Questions (Test #3, Fall 2020)

A client with venous thrombus reports having pain in the legs. The nurse should first: 1.Elevate the foot of the bed. 2.Elevate the legs by using a pillow under the knees. 3.Encourage adequate fluid intake. 4.Massage the lower legs.

1 Venous stasis can increase pain. Therefore, proper positioning in bed with the foot of the bed elevated or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience. Placing a pillow under the knees causes flexion of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood flow. Fluids are encouraged to maintain normal fluid and electrolyte balance but do little to relieve pain. Therapeutic massage to the legs is discouraged because of the danger of breaking up the clot.

The nurse is preparing to administer warfarin. The client's current laboratory values are as follows: PT 22, PT 39 Control, 12.9 Control 36, INR 3.6, Which intervention should the nurse implement? Select all that apply. 1. Question administering the medication. 2. Prepare to administer vitamin K. 3. Notify the HCP to increase the dose. 4. Administer the medication as ordered. 5. Assess the client for abnormal bleeding

1,2,5 1. Warfarin (Coumadin) is an oral anticoagulant. Coumadin requires careful monitoring of lab values in order to maintain the INR between 2 and 3. The INR is above the therapeutic range; therefore, the nurse should question administering this medication. 2. Vitamin K is the antidote for warfarin (Coumadin) toxicity; therefore, the nurse may administer this with an HCP order. 3. There is no reason to notify the HCP to request an increase in the dose because the client is above the therapeutic range. 4. The INR is above therapeutic range; therefore, the nurse should not administer the medication. Coumadin requires careful monitoring of lab values in order to maintain the INR between 2 and 3. 5. The INR is above therapeutic range; therefore, the nurse should assess the client for bleeding. MEDICATION MEMORY JOGGER: When trying to remember which laboratory value correlates with which anticoagulant, here's a helpful hint: "PT boats go to war (warfarin), and if you cross the small 't's' in 'Ptt' with one line it makes an 'h' (heparin)."

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered

1,3,4,5 1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. 2. Firm pressure reduces the risk for bleeding into the tissues. 3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. 4. Invasive procedures increase the risk of tissue trauma and bleeding. 5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot resulting in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions applicable in these alternative questions.

The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor? 1. Blood urea nitrogen (BUN) levels. 2. Bilirubin levels. 3. International normalized ratio (INR). 4. Partial thromboplastin time (PTT)

3 1. BUN laboratory tests are measurements of renal functioning. 2. Bilirubin is a liver function test. 3. PT/INR is a test to monitor warfarin (Coumadin) action in the body. 4. PTT levels monitor heparin activity. TEST-TAKING HINT: The test taker should devise some sort of memory-jogging mnemonic or aid to remember which laboratory test monitors for which condition. Try "PT boats go to war," to recall that PT monitors warfarin.

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour ride, the nurse should advise the client to: 1.Perform arm circles while riding in the car. 2.Perform ankle pumps and foot range-of-motion exercises. 3.Elevate the legs while riding in the car. 4.Take an ambulance home.

2 Performing active ankle and foot range-of-motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of: 1.Aortic aneurysm. 2.Deep vein thrombosis (DVT) in the left leg. 3.IV drug abuse. 4.Intermittent claudication.

2 The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to: 1.Avoid exercise. 2.Lose weight. 3.Perform leg lifts every 4 hours. 4.Wear support hose, using rubber bands to hold the stockings up.

2 The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Depending on the individual, leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up.

The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every four (4) hours and prn. 5. Assess Homans' sign every 24 hours.

2,3,4 1. Sequential compression devices provide gentle compression of the legs to prevent DVT, but they are not used to treat DVT because the compressions could cause the clot to break loose. 2. Clients should be on bedrest for five (5) to seven (7) days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing embolization. 3. Bedrest and limited activity predispose the client to constipation. Fluids and diets high in fiber will help prevent constipation. Fluids will also help provide adequate fluid volume in the vasculature. 4. The client will be administered a heparin IV drip, which should be monitored. 5. Homans' sign is assessed to determine if a DVT is present. This client has already been diagnosed with a DVT. Manipulating the leg to determine the presence of Homans' sign could dislodge the clot. TEST-TAKING HINT: Two (2) of the answer options are used to determine if a DVT is present or to prevent one. The test taker should not become confused about treat

The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump? _________

20 mL/hr.

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhagic areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client's PTT level. 3. Explain this results from the medication. 4. Assess the client's vital signs.

3 1. This occurs from the administration of the low molecular weight heparin and is not a reason to notify the HCP. 2. A therapeutic range will not be achieved with LMWH, and PTT levels are usually not done. 3. This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication. 4. Assessing the vital signs will not provide any pertinent information to help answer the client's question. TEST-TAKING HINT: Before selecting "Notify the HCP," the test taker should ask, "What will the HCP do with this information? What can the HCP order or do to help the purple hemorrhaged areas?" This would cause the test taker to

The client diagnosed with rule-out deep vein thrombosis (DVT) is experiencing dyspnea and chest pain on inspiration. On assessment, the nurse finds a respiratory rate of 40. Which medication should the nurse anticipate the HCP ordering? 1. Warfarin. 2. Aspirin. 3. Heparin. 4. Ticlopidine

3 1. Warfarin (Coumadin) is an oral anticoagulant. An oral anticoagulant would not be prescribed in an acute situation. 2. Aspirin is an antiplatelet useful to prevent myocardial infarction and cerebrovascular accident, but not used as treatment of PE. 3. Heparin is the medication of choice for treating PE, which the nurse should suspect with these signs and symptoms. IV heparin will prevent further clotting. 4. Ticlopidine (Ticlid) is a medication used to treat arterial, not venous, conditions. MEDICATION MEMORY JOGGER: Remember that antiplatelets work in the arteries and anticoagulants work in the veins.

The nurse is discharging the female client diagnosed with a pulmonary embolism (PE) who is prescribed warfarin. Which statement indicates the client understands the medication teaching? 1. "I should use a straight razor when I shave my legs." 2. "I will use a hard-bristled toothbrush to clean my teeth." 3. "An occasional nosebleed is common with this drug." 4. "It will be important for me to have regular bloodwork done."

4 1. The client is at risk for bleeding and should be encouraged to use an electric razor. 2. The client is at risk for bleeding and a soft-bristled toothbrush should be used. 3. Any abnormal bleeding, such as a nosebleed, is not expected and should be reported to the HCP. Unexplained bleeding is a sign of toxicity. 4. Warfarin (Coumadin) is an oral anticoagulant. The client's INR is monitored at routine intervals to determine if the medication is within

The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________

880 units

The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. 2. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged. 4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus

1 1. A complication of immobility after surgery is developing a DVT. This client with left calf pain should be assessed for a DVT. 2. This is an expected finding. 3. Clients who require an open cholecystectomy frequently are discharged with a T-tube. This client needs to know how to care for the tube before leaving, but this is not a priority over a possible surgical complication. 4. This is expected for this client. TEST-TAKING HINT: In priority-setting questions, the test taker must decide if the information in the answer option is expected or abnormal for the situation. Based on this, options "2," "3," and "4" can be eliminated.

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.

1 1. A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus. 2. An immobile client should be turned at least every two (2) hours, but a pressure area is not life threatening. 3. This is expected in a client who has a large upper abdominal incision. It hurts to breathe deeply. The nurse should address this but has some time. The life-threatening complication is priority. 4. Clients who have had inguinal hernia repair often have difficulty voiding afterward. This is expected. TEST-TAKING HINT: The test taker should determine which option contains information that indicates a potentially life-threatening situation. This is the priority client.

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

1 1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. 2. Pulmonary emboli are not caused by atherosclerosis; this is not an appropriate discharge instruction for a client with a pulmonary embolus. 3. Infection does not cause a PE; this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism. TEST-TAKING HINT: The test taker must know deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important intervention. The test taker can attempt to eliminate answers by trying to determine which disease process is appropriate for the intervention.

The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin.

1 1. The nurse should check the laboratory values pertaining to the medications before administering the medications. 2. The client will be administered an oral medication while still receiving a heparin drip to allow time for the client to achieve a therapeutic level of the oral medication before discontinuing the heparin. The effects of oral medications take three (3) to five (5) days to become therapeutic. 3. The laboratory values should be noted before administering the medications. 4. The heparin will be continued for three (3) to five (5) days before being discontinued. TEST-TAKING HINT: Knowing the actions of each medication, as well as the laboratory tests that monitor the safe range of dosing, is important. Remember, assessment is first. Assess blood levels and then administer the medication

The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

1 1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis. 2. An ABG evaluates oxygenation level, but it does not diagnose a pulmonary embolus (PE). 3. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 4. An MRI is a noninvasive test that detects a deep vein thrombosis (DVT), but it does not diagnose a pulmonary embolus. A computed tomography (CT) scan or ventilation/ perfusion (V/Q) scan would be used to confirm the diagnosis. TEST-TAKING HINT: The key to answering this question is "confirms the diagnosis." The test taker should eliminate options "2" and "3" based on the fact these are diagnostic tests used for many disease processes and conditions.

The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement first? 1. Stay with the client and call the Rapid Response Team (RRT). 2. Assess the client's vital signs. 3. Have the unlicensed assistive personnel (UAP) stay with the client. 4. Check the client's telemetry reading.

1 1. These clinical manifestations could indicate a pulmonary embolus. The nurse should not leave the client but should get help as soon as possible. The rules of the RRT are that anyone can call an RRT if a concern is noted, and no one will suffer consequences because one was called and it was determined that the client was not in serious danger. 2. The nurse's first action is to stay with the client and call for help. 3. The UAP cannot be assigned an unstable client. 4. The telemetry reading is not important in regard to the current clinical manifestations. TEST-TAKING HINT: Remember, "if in stress, do not assess"; the nurse must implement an intervention that will directly affect the client outcome.

The nurse is preparing to hang the next bag of heparin. The client's current laboratory values are as follows: PT 13.4, PTT 92, Control 12.9, Control 36 INR 1, Which intervention should the nurse implement? 1. Discontinue the heparin infusion. 2. Prepare to administer protamine sulfate. 3. Notify the HCP. 4. Assess the client for bleeding.

1 1. This would be the first intervention because the client is above the therapeutic range. The therapeutic range for heparin is 1.5 to 2.0 times the control, or 54 to 72. The client's PTT of 92 places the client at risk for bleeding; therefore, the nurse must prevent further infusion of medication. 2. Protamine sulfate is the antidote for heparin, but the nurse would not administer this first. Discontinuing the infusion of heparin for a few hours may be sufficient to correct the overdose. 3. The HCP should be notified of the client's situation, but it is not the first intervention. 4. Assessment is the first step in the nursing process, but if the client is in "distress" or experiencing a complication, the nurse should first treat the client. MEDICATION MEMORY JOGGER: When trying to remember which laboratory value correlates with which anticoagulant, here's a helpful hint: "PT boats go to war (warfarin), and if you cross the small 't's' in 'Ptt' with one line it makes an 'h' (heparin).

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1.Elevate the head of the bed 30 to 45 degrees. 2.Encourage the client to cough and deep breathe. 3.Auscultate the lungs to detect abnormal breath sounds. 4.Contact the physician

1 Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply. 1.Checking urine for bright blood and a dark smoky color. 2.Walking daily as a good exercise. 3.Using garlic and ginger, which may decrease bleeding time. 4.Performing foot/leg exercises and walking around the airplane cabin when on long flights. 5.Preventing DVT because of risk of pulmonary emboli. 6.Avoiding surface bumps because the skin is prone to injury.

1, 2, 4, 5, 6 Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when a client is on anticoagulant therapy. Clients who have had previous DVTs should avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return. Instructing the client about prevention measures is important because clients with DVT are at high risk for pulmonary emboli (PE), which can be fatal. The client can be taught risk factors for DVT and PE. In addition, recommendations for prevention of these events also are standard protocol in practice and should[...]

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

2 1. Arterial blood gases would be included in the client problem "impaired gas exchange." 2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client problem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of the heart's inability to pump blood. Decreased blood to the extremities results in cyanosis and cold extremities. Content - Medical: Integrated Nursing Process -

Which actions should the surgical scrub nurse take to prevent personally developing a DVT? 1. Keep the legs in a dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have an elevated heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery

2 1. Keeping the legs dependent and standing still will promote the development of a DVT. 2. Flexing the leg muscles and changing positions assist the blood to return to the heart and move out of the peripheral vessels. 3. The nurse should wear support stockings, not socks, and change the types of shoes worn from day to day, varying the type of heels. 4. This is not in the client's best interest. TEST-TAKING HINT: The test taker can eliminate option "4" by imagining the reaction of the HCP if this were done. Thewords "dependent" and "still" make option "1" wrong.

The client is being admitted to the medical unit with a diagnosis of anemia. The nurse is reconciling the client's medication list. List of home medications: dabigatran daily, levothyroxine daily, digoxin daily, prednisone tapering daily with 2 days left before discontinuing, warfarin every evening. Which information should the nurse notify the HCP of immediately? 1. Notify the HCP of the levothyroxine and digoxin. 2. Notify the HCP of the dabigatran and warfarin. 3. Notify the HCP of the prednisone tapering schedule. 4. Notify the HCP to request a digoxin antidote

2 1. Levothyroxine and digoxin have no indications that they cannot be administered to the client concurrently. 2. Dabigatran (Pradaxa), a direct thrombin inhibitor, and warfarin (Coumadin), a anticoagulant that impacts prothrombin, are both anticoagulant medications. This would place the client at high risk for uncontrolled bleeding. The HCP should be notified immediately (STAT). The anemia may be the result of internal bleeding. Coumadin has vitamin K (AquaMEPHYTON) as an antidote, and in 2016 the U.S. Federal Drug Administration (FDA) approved idarucizumab (Praxbind) as an antidote for Pradaxa. The HCP should be notified so that the appropriate tests can be performed and treatment initiated. 3. The nurse should ensure that the client's prednisone schedule is resumed, but this can be done on routine rounds. 4. The antidote for digoxin is Digibind, but the client has anemia possibly from bleeding. Digoxin does not affect anemia. MEDICATION MEMORY JOGGER: The test taker must recognize medications and how they work on the body.

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? 1. The client's partial thromboplastin time (PTT) is 38. 2. The client's international normalized ratio (INR) is 5. 3. The client's prothrombin time (PT) is 22. 4. The client's erythrocyte sedimentation rate (ESR) is 10.

2 1. The PTT is not monitored to determine a serum therapeutic level for warfarin; normal is 30 to 45. 2. The INR therapeutic range is two (2) to three (3) for a client receiving warfarin. The INR may be allowed to go to 3.5 if the client has a mechanical cardiac valve, but nothing in the stem of the question indicates this. 3. The PT is monitored for oral anticoagulant therapy and should be 1.5 to 2 times the normal of 12; therefore, 22 is within therapeutic range and would not warrant the nurse questioning administering this medication. 4. The ESR is not monitored for oral anticoagulant therapy

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

2 1. The client needs oxygen, but the nurse can intervene to help the client before applying oxygen. 2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. 3. A pulse oximeter reading is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. When the client is in distress, do not assess.

The client who was been prescribed rivaroxaban following a diagnosis of PE presents to the clinic with reports of dark, tarry stools. Which intervention should the nurse implement first? 1. Call 911 and have the paramedics take the client to the ED. 2. Assess the client for any other signs of bleeding. 3. Check the client's prothrombin time (PT)/international normalized ration (INR) levels. 4. Notify the HCP of the dark, tarry stools

2 1. The client presented to the outpatient clinic, so the nurse should fi rst determine how much bleeding has occurred. The nurse knows the consistency and color of the stools, but not the duration or amount. The nurse should assess the client before arranging for an emergency transfer. 2. The nurse should first assess the client for clinical findings of bleeding such as decreased blood pressure and increased pulse, bruising, hematuria, hemogram, etc. The nurse should then notify the HCP at the clinic, then call 911 if needed. Rivaroxaban (Xarelto) is a Factor Xa Inhibitor and PT/INR would not measure the impact of the medication on the body. 3. Rivaroxaban (Xarelto) is a Factor Xa Inhibitor and PT/INR would not measure the impact of the medication on the body. 4. The nurse should notify the HCP after the nurse has fully assessed the client's bleeding. MEDICATION MEMORY JOGGER: The test taker should recognize that both rivaroxaban and warfarin are anticoagulant. The nurse should at least understand that medications which impact the body in a similar manner will have a risk of overtreating the issue and result in problems for the client.

The nurse just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with DVT who is complaining of chest pain. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis who has non-bloody diarrhea

2 1. This blood pressure is elevated, but it is not life threatening. 2. The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by the nurse. 3. A pulse oximeter reading of greater than 93% is within normal limits. 4. Non bloody diarrhea is an expected sign of ulcerative colitis and would not require immediate intervention by the nurse. TEST-TAKING HINT: The nurse should assess the client who has abnormal assessment data or a life-threatening condition first when determining which client is priority.

Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever

2 1. This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a sign of a pulmonary embolism. 2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath. 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications but not specifically a pulmonary embolism. TEST-TAKING HINT: The key to selecting option "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in option "3" to eliminate this as a possible correct answer, and option "4" is nonspecific for a pulmonary embolism

The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain before undressing the client. 2. The UAP begins to massage and rub lotion into the client's calf. 3. The UAP tests the temperature of the water with the wrist before starting. 4. The UAP collects all the linens and supplies and brings them to the room

2 1. This protects the client's privacy. 2. The UAP could dislodge a blood clot in the leg when massaging the calf. The UAP can apply lotion gently, being sure not to massage the leg. 3. Testing the temperature of the water prevents scalding the client with water that is too hot or making the client uncomfortable with water that is too cold. 4. Collecting supplies needed before beginning the bath is using time wisely and avoids interrupting the bath to go and get items needed. TEST-TAKING HINT: This is an "except" question, so all options except one (1) will be actions that should be encouraged. The test taker should not jump to the first option and choose it as the correct answer

The client diagnosed with a pulmonary embolism (PE) is receiving IV heparin, and the HCP prescribes 5 mg warfarin orally once a day. Which statement best explains the scientific rationale for prescribing these two anticoagulants? 1. Coumadin interferes with production of prothrombin. 2. It takes 3 to 5 days to achieve a therapeutic level of Coumadin. 3. Heparin is more effective when administered with warfarin. 4. Coumadin potentiates the therapeutic action of heparin.

2 1. Warfarin (Coumadin) is an oral anticoagulant. This is the scientifi c rationale for why Coumadin is prescribed to prevent thrombus formation, but it is not the rationale for why the medications are administered together. 2. Warfarin (Coumadin) is an oral anticoagulant. Heparin has a short half-life and is prescribed as soon as a PE is suspected. The client must go home having taken an oral anticoagulant such as Coumadin, which has a long half-life and needs at least 3 to 5 days to reach a therapeutic level. Discontinuing the heparin prior to achieving a therapeutic level of Coumadin places the client at risk for another PE. 3. Heparin and warfarin work in different steps in the bleeding cascade. 4. This is a false statement. Heparin and warfarin work in different steps in the bleeding cascade

Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. The nurse should first: 1.Offer analgesics as prescribed and apply the compression devices. 2.Leave the compression devices off and contact the physician to report the assessment findings. 3.Massage the area of discomfort before applying the compression devices. 4.Leave the compression devices off and report assessment findings to the oncoming shift.

2 Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the physician; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the physician as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus

The nurse is administering alteplase to a client diagnosed with massive pulmonary embolism (PE). Which data indicates the medication is effective? 1. The client's partial thromboplastin time (PTT) level is within therapeutic range. 2. The client is able to ambulate to the bathroom. 3. The client denies chest pain on inspiration. 4. The client's chest x-ray is normal.

3 1. The PTT test is used to monitor the anticoagulant heparin, not the thrombolytic alteplase (Activase). 2. A client with a massive PE would be on bedrest; therefore, ambulating would not indicate the medication is effective. 3. Alteplase (Ativase) is a thrombolytic. To determine if the medication is effective, the nurse must assess for an improvement in the signs or symptoms for the condition for which the medication was ordered. Chest pain is one of the most common symptoms of PE. Denial of chest pain would indicate the medication is effective. 4. In the client diagnosed with a PE the chest x-ray is usually normal; therefore, it would not be used to de

The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3 . Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

3 1. An INR of 2 to 3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; therefore, the nurse should administer the insulin. 3. A normal PTT is 39 seconds, and for heparin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clotting and the medication should be held. 4. This is a normal blood pressure and the nurse should administer the medication. TEST-TAKING HINT: This question is asking the test taker to select a distracter with assessment data that are unsafe for administering the medication. The test taker must know normal labor

The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3 1. The ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. 3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. 4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/hour and would not warrant immediate intervention by the nurse. TEST-TAKING HINT: This question is asking the test taker to select abnormal, unexpected, or life-threatening assessment data in relationship to the client's disease process. A pulse oximeter reading of less than 93% indicates severe hypoxia and requires immediate intervention.

The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green, leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top

3 1. The client will be taking an oral anticoagulant, warfarin (Coumadin). Prothrombin time (PT) and international normalized ratio (INR) levels, not partial thromboplastin time (PTT), are monitored when this medication is taken. The client should be in therapeutic range before discharge. The HCP will determine how often to monitor the levels, usually in two (2) to three (3) weeks and then at three (3)- to six (6)-month intervals. 2. The client is not restricted to the home. The client should not take part in any activity that does not allow frequent active and passive leg exercises. In an airplane, the client should be instructed to drink plenty of fluids, move the legs up and down, and flex the muscles. If in an automobile, the client should stop to take frequent breaks to walk around. 3. Green, leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods will interfere with the action of warfarin. Red or brown urine may indicate bleeding. 4. The client should be instructed to wear stockings that do not constrict any area of the leg. TEST-TAKING HINT: The test taker must know laboratory data for specific medications. The INR and PT are monitored for oral anticoagulants. Remember: "PT boats go to war" (warfarin). PTT monitors heparin ("tt" is like an H for heparin).

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose

3 1. The client would not be experiencing abnormal bleeding with this INR. 2. This is the antidote for an overdose of anticoagulant and the INR does not indicate this. 3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication. 4. There is no need to increase the dose; this result is within the therapeutic range. TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.

The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? 1. Myocardial infarction. 2. Pneumonia. 3. Pulmonary embolus. 4. Pneumothorax.

3 1. The nurse would not suspect a myocardial infarction for a client with a DVT who suddenly has chest pain. 2. These signs and symptoms should not make the nurse think the client has pneumonia. 3. Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary arterial system, and causes the chest pain; the client often feels as if he or she is going to die. 4. Chest pain is a sign of pneumothorax, but it is not a complication of deep vein thrombosis.

The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs

3 1. There is nothing that contraindicates the use of a stool softener, and use of one may be recommended if the client is prone to constipation and hard stool that could cause some bleeding from hemorrhoids. 2. A Medic Alert bracelet notifies any emergency HCP of the client's condition and medications. 3. Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin. 4. This would be recommended for the client if the footrest does not restrict blood flow in the calves. TEST-TAKING HINT: The test taker can eliminate option "1" by realizing that a stool softener would not cause a problem and could help with an unrelated problem. Medic Alert bracelets are frequently recommended for many clients with certain diseases and conditions.

A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is: 1.Arteriosclerosis. 2.Aneurysm formation. 3.Deep vein thrombosis (DVT). 4.Varicose veins."

3 DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered causes of pulmonary embolism

Which of the following clients is at risk for varicose veins? 1.A client who has had a cerebrovascular accident. 2.A client who has had anemia. 3.A client who has had thrombophlebitis. 4.A client who has had transient ischemic attacks.

3 Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.

A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. The client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first: 1.Administer pain medication. 2.Assess edema in the left leg. 3.Assess color and temperature of the left leg. 4.Encourage the client to change her position.

3 The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data

The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help to prevent DVTs by movement of the blood through the veins

4 1. Passive range-of-motion exercises are recommended to prevent contracture formation and muscle atrophy, but this is a musculoskeletal complication, not a cardiovascular one. 2. If the client is on a ventilator, then the paralysis associated with GB syndrome has moved up the spinal column to include the muscles of respiration. Passive range-of-motion exercises are done by the staff; the client will not be able to do active ROM. 3. Range-of-motion exercises will not alleviate the pain of GB syndrome. 4. One reason for performing range-ofmotion exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT. TEST-TAKING HINT: The question is asking for a cardiovascular reason for range-of-motion exercises. Options "1," "2," and "3" do not have any cardiovascular component. Only option "4" discusses veins and blood.

Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."

4 1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding, so the teaching is not effective. 2. This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy, so the teaching is not effective. 3. Aspirin, enteric-coated or not, is an antiplatelet, which may increase bleeding tendencies and should be avoided, so the teaching is not effective. 4. The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy. The client understands the teaching. TEST-TAKING HINT: This is a higher level question in which the test taker must know clients with a pulmonary embolus are prescribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, the option stating "wear a Medic Alert band" is a good choice because many disease processes require the client to take long-term medication and a health-care provider should be aware of this

The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, "Something is really wrong with me." Which intervention should the nurse implement first? 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula.

4 1. The heparin drip may be increased because the client has now thrown a pulmonary embolus (PE), but this needs an HCP's order. 2. The HCP will be notified because the client has a suspected embolus, but it is not the first intervention. 3. The client has probably thrown a pulmonary embolus, and assessing the lungs will not do anything for a client who may die. PEs are life threatening, and assessing the client is not priority in a life-threatening situation. 4. The client probably has a pulmonary embolus, and the priority is to provide additional oxygen so oxygenation of tissues can be maintained.

The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

4 1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. 4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which makes this option incorrect. The test taker should apply the body system of the disease process to eliminate option "2" as a correct answer.

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has prescribed 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below PTT:12.5 INR 2.0 Platelet count: 50,000 Based on these results, the nurse should: 1.Assess the client for bleeding. 2.Administer the medication. 3.Inform the physician. 4.Withhold the dose of Lovenox.

4 Based on the laboratory findings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician

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 room, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: 1.Administering aspirin as prescribed. 2.Encouraging green leafy vegetables in the diet. 3.Monitoring the client's prothrombin time (PT). 4.Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR)

4 Heparin dosage is usually determined by the physician based on the client's aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium (Coumadin)

The nurse observes that an older female has small-to-moderate, distended, and tortuous veins running along the inner aspect of her lower legs. The nurse should: 1.Apply a half-leg pneumatic compression device. 2.Suggest the client contact her physician. 3.Assess the client for foot ulcers. 4.Encourage the client to avoid standing in one position for long periods of time.

4 The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the physician at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time.

The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of: 1.Atherosclerosis. 2.Diabetes. 3.Vasospastic disorder (Raynaud's disease). 4.Thrombophlebitis.

4 The data suggest an increased risk of thrombophlebitis. The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for atherosclerosis include genetics, older age, and a high-cholesterol diet. Risk factors for diabetes include genetics and obesity. Risk factors for vasospastic disorders include cold climate, age (16 to 40), and immunologic disorders

In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should: 1.Restrict fluids. 2.Encourage deep breathing. 3.Assist the client to remain sedentary. 4.Use pneumatic compression stockings.

4 The use of pneumatic compression stockings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid intake, and administering anticoagulant medication as prescribed. Deep breathing would be encouraged postoperatively, but it does not prevent DVT.

The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following: 1.Turning every 2 hours. 2.Passive and active range-of-motion exercises. 3.Use of thromboembolic disease (TED) support hose. 4.Maintaining the client in the supine position.

4 Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities

A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications? 1.Air embolus. 2.Fat embolus. 3.Stress fractures. 4.Thrombophlebitis

4 Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.