Nursing 265 Week 10

Which client is at greatest risk for the development of a venous thrombosis?

A 68-year-old male on bed rest following a left hip fractureVenous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.

What intervention should the nurse implement when caring for a client 24-hours post-thyroidectomy?

Check the back and sides of the operative siteBleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods encouraged.Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. What action should the nurse take?

Consider this an expected eventAs a result of the trauma of surgery, some bleeding can be expected for four to five hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A patient presents with epistaxis. Which interventions are appropriate to control the bleeding?

Decongestants H1-antihistamines

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities?

Duplex venous doppler Rationale Duplex venous doppler records an ultrasound of the veins, including blood flow abnormalities of the lower extremities, aiding detection of deep vein thrombosis. Thermography, which measures the heat radiating from the skin surface, is used to determine client response to antiinflammatory drug therapy and inflamed joints. Plethysmography is used to record variations in volume and pressure of blood passing through tissues; test is nonspecific. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease.

What should the nurse do to prevent thrombus formation after most surgeries?

Encourage the client to ambulate with assistance every few hours.Ambulation is essential to promote venous return and prevent thrombus formation. Keeping the client's bed gatched to elevate the knees causes increased popliteal pressure and impairs venous return. Having the client dangle the legs off the side of the bed causes increased popliteal pressure and impairs venous return. Having the client use an incentive spirometer every hour helps prevent atelectasis, not thrombi.

What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel?

Epistaxis (bleeding from the nose) Rationale The high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose blowing), makes it a frequent site of hemorrhage. Nausea, chest pain, and elevated temperature usually are not associated with anticoagulant therapy.

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy?

Hemorrhage Rationale In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session?

Increased blood viscosity Rationale Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first?

Instruct the client to remain in bed and notify the health care provider. Rationale Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis. Activity should be limited. Bed rest is indicated to prevent the possibility of further damage. Symptoms indicate a possible problem with thrombus formation. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present.Test-Taking Tip: Make educated guesses when necessary.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus?

Pink (Rationale:With a pulmonary embolus there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.)

Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for what purpose?

Provide prophylaxis against postoperative thrombus formation. (Rationale: Enoxaparin (Lovenox), a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III.)

What should the nurse teach a client who is taking warfarin?

Report episodes of spontaneous bleeding. Rationale Warfarin is an anticoagulant; therefore, excessive bleeding, especially that which occurs spontaneously and unrelated to injury, may require a dosage adjustment for safety reasons. Activity or inactivity is unrelated to the need to alter the dose of warfarin. The dose should not be altered without healthcare supervision. The problem of bleeding is more significant than infection when a client is taking warfarin. Green vegetables that contain vitamin K, which is necessary for the synthesis of clotting factors VII, IX, and X, should be kept consistent in the diet from week to week; increased consumption will decrease the action of warfarin, and a decreased consumption will increase the action of warfarin.

What is the first process that occurs during normal hemostasis?

Vascular response

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin?

acetylsalicylic acid (aspirin)Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants. Ferrous sulfate does not affect warfarin; it is used for red blood cell synthesis. Atenolol is a beta blocker that reduces blood pressure; it does not affect bleeding. Chlorpromazine is a neuroleptic; it does not affect bleeding.

A client with a history of a herniated nucleus pulposus is scheduled for total hip replacement surgery. To prevent the most common complication associated with this type of surgery, the nurse should instruct the client to perform which activity?

plantar flexion and dorsiflexion exercises Rationale Plantar flexion and dorsiflexion exercises promote venous return, which helps prevent venous thrombus formation, the most common complication after hip surgery. Straight-leg raises are contraindicated for a client who has a history of a herniated nucleus pulposus. Buerger-Allen exercises stimulate collateral circulation for clients with peripheral vascular disease; they are seldom used, because walking is considered a more effective exercise. Although deep breathing and coughing should be encouraged to prevent respiratory complications, thrombus formation is a more common complication than respiratory complications after a total hip replacement.Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms Rationale The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Both vascular dementia and dementia of the Alzheimer type are associated with this deficit in function. Memory impairment may or may not be a symptom of vascular dementia, it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment, but the client does not have abrupt onset of symptoms. Difficulty making decisions is a major part of Alzheimer disease, but may not be manifested with vascular dementia, depending on which part of the brain is affected. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do?

Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?

They help the venous blood return to the heart.Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than 30 minutes. The purpose of pneumatic compression devices is to increase venous return. Clients often complain about pneumatic compression devices being hot and itchy. In addition to the pneumatic compression devices, a mechanical form of DVT prophylaxis, pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic?

International normalized ratio (INR) Rationale Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

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

Joints Rationale Activity can result in bleeding in children with hemophilia; therefore weight-bearing joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from the trauma of direct force. The cerebrum is protected by the skull and is not likely to be injured. Bleeding from bones themselves is not common without other associated trauma.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

Which adverse effect can be seen in a female client with gonadotropin deficiency and undergoing hormone replacement therapy?

ThrombosisA female client with gonadotropin deficiency is treated by replacement therapy of combined hormones, namely estrogen and progesterone. The side effect of this therapy is the increased risk of thrombosis or formation of blood clots in deep veins. Hypertension is a side effect of estrogen-progesterone therapy. Dehydration and increased thirst could indicate vasopressin deficiency.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do?

Prevent clot formation Rationale Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis. These isotonic exercises are being performed on the unaffected extremity; there should be no discomfort. Although isotonic exercises do promote muscle strength, that is not the purpose of these exercises at this time. Active ROM exercises help prevent, not limit, venous inflammation.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?

Right side-lyingThe liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis?

Spiral (helical) computed tomographic angiography (CTA) Rationale A spiral (helical) computed tomographic angiography (CTA) is considered the gold standard for a pulmonary embolism (PE) medical diagnosis. The spiral CTA also has the added advantage of diagnosing other pulmonary abnormalities. A pulmonary angiography is still used as a PE diagnostic test, usually if the client also has coronary disease and invasive treatment (i.e., angioplasty) may become necessary; however, it is no longer the gold standard because it is expensive and invasive, and the spiral CTA has excellent accuracy and better accessibility. Ventilation/perfusion (V/Q) scans are currently used only in certain circumstances such as when the client has contrast dye allergy. D-dimer and arterial blood gas (ABG) laboratory tests are typically prescribed for a client with a possible PE; however, these tests are not specific or sensitive enough to be used alone to make the PE diagnosis. An ABG is used to evaluate the client's oxygenation status during medical diagnosis and treatment to determine if additional emergency treatment is needed, such as intubation and mechanical ventilation. A D-dimer simply reveals the presence or absence of fibrin split products which occur when a blood clot degrades or breaks down; however, about half of clients with a PE still test negative (a normal result) and several other conditions can produce a positive D-dimer result.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed. Rationale To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. The stockings apply uniform pressure; loose elastic bandages may slip, creating uneven, ineffective pressure. Edema also may result.STUDY TIP: Develop a realistic plan of study. Do not set rigid, unrealistic goals.

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause?

Warfarin Rationale Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.