UNIT 2 EXAM: CLOTTING Exemplars: Thrombocytopenia, Hemophilia A and B, Venous Thrombosis

1. A pt. is receiving continuous IV heparin for tx of a DVT, has a aPTT of 110 seconds. What should the RN do? - Continue the infusion no change - Re draw the aPTT stat - Increase the drip rate per protocol - Hold the infusion for 1 hour and decrease rate per protocol

Hold the infusion for 1 hour and decrease rate per protocol

coagulation studies for heparin

aPTT

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1.Pregnancy 2.Inactivity 3.Aerobic exercise 4.Tight clothing

2 A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

A 10-year-old child is found to have hemophilia. The nurse is explaining how hemophilia is inherited. What is the best explanation of the genetic factor that is involved? 1.It follows the Mendelian law of inherited disorders. 2.The mother is a carrier of the disorder but is not affected by it. 3.It is an autosomal dominant disorder in which the woman carries the trait. 4.A carrier may be male or female, but the disease occurs in the sex opposite that of the carrier

2 The hemophilia gene is carried on the X chromosome but is recessive. Therefore the female is the carrier (an unaffected XO and an affected XH). If the male receives the affected XH (XHYO), he will have the disorder. Hemophilia is carried by the female; the Mendelian laws of inheritance are not sex specific. Hemophilia is a sex-linked recessive disorder. Females only carry the trait; usually males are affected.

aPTT normal range

25-35 seconds

The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition? 1.Hepatic disease 2.Cirrhosis of the liver 3.Factor VII deficiency 4.Deep vein thrombosis

4 The normal PT for an adult ranges from 11 to 12.5 seconds. A decreased PT may be noted in many conditions, including arterial occlusion, deep vein thrombosis, edema, myocardial infarction, peripheral vascular disease, and pulmonary embolism. An increased PT would be noted in the conditions identified in the remaining options.

coagulation studies for aspirin

pt

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? 1.Prevents extension of the clot 2.Reduces the size of the thrombus 3.Dissolves the blood clot in the vein 4.Facilitates absorption of red blood cells

1 Heparin interferes with activation of prothrombin to thrombin and inhibits aggregation of platelets. Heparin does not reduce the size of a thrombus. Heparin does not dissolve blood clots in the veins. Heparin does not facilitate the absorption of red blood cells.

A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia? 1.Avoid traumatic injuries and exposure to infection. 2.Perform frequent mouth care with a firm toothbrush. 3.Increase oral fluid intake to a minimum of 3 L daily. 4.Report any unusual muscle cramps or tingling sensations in the extremities

1 Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. Aggressive oral hygiene can precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. Muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. 1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a cold." 3."I should use an enema instead of laxatives for constipation." 4."I definitely will play football with my friends this weekend." 5."I should use a soft-bristled toothbrush to avoid mouth trauma."

1,2,5 Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia should be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply. 1.Pain in the calf 2.Intermittent claudication 3.Redness in the affected area 4.Pitting edema of the lower leg 5.Ecchymotic areas around the ankle 6.Localized warmth in the lower extremity

1,3,6 Pain is related to the edema associated with the inflammatory response. Redness is related to vasodilation and the inflammatory response. Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot. Warmth is related to vasodilation. Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease. Although some localized edema occurs, pitting edema does not occur in thrombophlebitis. Ecchymosis is a sign of bleeding; thrombophlebitis is caused by a clot.

A prescription reads heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.

16 Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of heparin sodium in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review? 1.Hemoglobin (Hgb) 2.Prothrombin time (PT) 3.Red blood cell (RBC) level 4.Partial thromboplastin time (PTT)

2 PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy.

After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? 1.Increase the IV rate of heparin. 2.Interrupt the infusion and notify the primary healthcare provider of the aPTT result. 3.Document the result on the medical record and recheck the aPTT in 4 hours. 4.Call the primary healthcare provider to obtain a prescription for a low-molecular-weight heparin

2 The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary healthcare provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

Which client is at greatest risk for the development of a venous thrombosis? 1.A 76-year-old female with a 100-pack-per-year smoking history and hypertension 2.A 68-year-old male on bed rest following a left hip fracture 3.A 59-year-old male who is an intravenous drug user with hyperlipidemia 4.A 42-year-old female with Factor V Leiden mutation on warfarin

2 Venous 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.

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results? 1.Collaborate with the primary health care provider (PHCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2.Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. 3.Collaborate with the PHCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4.Collaborate with the PHCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.

2 When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the PHCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device? Record your answer using a whole number. ___ mL/hr

20 The ordered rate is 1000 u/hr. The available concentration is 25,000 u in 500 mL D5W. Make the necessary conversions and use dimensional analysis to determine the appropriate rate in mL/h. The ratio and proportion method is not appropriate for this situation.

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1.A clotting time of 10 minutes 2.An ammonia level of 10 mcg/dL (6 mcmol/L). 3.A platelet count of 50,000 mm3 (50 × 109/L) 4.A white blood cell count of 5000 mm3 (5.0 × 109/L)

3 Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 mm3 (150 to 400 × 109/L). When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L).

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. 1.Use a straight-edge razor for shaving. 2.Obtain a rectal temperature every 8 hours. 3.Check secretions for frank or occult blood. 4.Give vitamin K by the intramuscular route. 5.Encourage fluid intake to avoid constipation. 6.Provide oral sponges or a soft toothbrush for oral care

3,5,6 Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.

1. The client diagnosed with PE is in the ICU. Which data would need immediate intervention? - O2 sat of 88% - The client's telemetry occasionally exhibits PVCs - The client's ABGs are pH 7.36, PCO2 38, HCO3 24 - Urine output for the 12-hour shift is 800ml

O2 sat of 88%

aPTT therapeutic range

46-70 seconds

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client? 1.Take a baby aspirin every day 2.Ambulate early and frequently 3.Sit for prolonged periods of time 4.Place a warm soak on the legs daily

2 Early and frequent ambulation can help prevent thrombophlebitis. The nurse legally cannot recommend medications. Sitting for prolonged periods of time will increase the chance of thrombophlebitis. Warm soaks resolve inflammation; they do not prevent development of thrombophlebitis.

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client? 1.Edema of the left leg 2.Mobility of the left leg 3.Positive left-sided Babinski reflex 4.Presence of left arterial peripheral pulse

1 Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return. Difficulty with mobility occurs with musculoskeletal or neuromuscular problems. Positive left-sided Babinski reflex is associated with neurologic deficits in the corticospinal tracts. Presence of a left arterial peripheral pulse is made to determine the status of the arterial, not venous, system.

A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding? 1.Brain 2.Joints 3.Kidneys 4.Abdomen

2 The joints are the most commonly involved areas because of weight bearing and constant movement. Neither the brain, nor the kidneys, nor the abdomen is the most common site; however, bleeding may occur in any of these areas.

1. A patient with a left femoral DVT is started on warfarin. What lab should the nurse monitor? - aPTT - Platelets - INR - Bleeding time

INR

1. The pt. is at risk for developing at DVT post-op. Which would the nurse NOT include in the pt's plan of care? - Encourage the pt. to eat all meals OOB in a chair - The nurse will administer enoxaparin subq in the abdomen - The nurse will apply SCDs to the pt's lower extremities at bedtime - The pt. will ambulate daily

The nurse will apply SCDs to the pt's lower extremities at bedtime

INR normal range

0.8-1.2

The blood lab work for a client with purpuric lesions on the skin shows a thrombocyte count of 100,000 cells per microliter. Which nursing intervention would be priority in this patient to reduce the risk of bleeding? 1.Advising the client to drink plenty of fluids 2.Advising the client to perform bending exercises 3.Advising the client to use superabsorbent tampons 4.Advising the client to use alcohol-based mouthwashes

1 A client with purpuric lesions and a thrombocyte count of 100,000 cells per microliter has thrombocytopenia. Drinking plenty of fluids helps to prevent constipation and straining while having a bowel movement, thereby preventing bleeding. Performing bending exercises may lead to bleeding from the nose, and it is contraindicated. Usage of superabsorbent tampons may increase the chance of toxic shock syndrome (TSS) and result in severe infection or death. Usage of alcohol-based mouthwashes can dry the gums and increase bleeding.

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply. 1.Avoid intramuscular injections 2.Institute neutropenic precautions 3.Monitor the white blood cell count 4.Administer prescribed anticoagulants 5.Examine the skin for ecchymotic areas

1,5 Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased white blood cells (WBCs), not platelets. Thrombocytopenia refers to decreased platelets, not WBCs. Anticoagulants are contraindicated because of the increased bleeding risk.

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply. 1.Heparin 2.Clopidogrel 3.Warfarin 4.Enoxaparin 5.Acetylsalicylic acid

1,4 Heparin may be used during pregnancy because it does not cross the placental barrier and will not cause hemorrhage in the fetus. Enoxaparin does not cross the placental barrier; its classification for pregnancy is B. Clopidogrel is a platelet aggregation inhibitor. It is not used for thrombophlebitis; it is used to reduce the risk of brain attack, transient ischemic attack, unstable angina, and myocardial infarction. Warfarin crosses the placental barrier, causing hemorrhage in the fetus. Acetylsalicylic acid is a platelet aggregation inhibitor and is not recommended during pregnancy (D category).

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? 1.Normal 2.Increased 3.Decreased 4.Insignificant

3 The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? 1.Thermography 2.Plethysmography 3.Duplex venous doppler 4.Somatosensory evoked potential

3 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.

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1."I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."

4 Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information

A client with chronic liver disease reports, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. The nurse concludes that the client needs which additional supplement? 1.Bile salts 2.Folic acid 3.Vitamin A 4.Vitamin K

4 Fat-soluble vitamin K is essential for synthesis of prothrombin by the liver; a lack results in hypoprothrombinemia, inadequate coagulation, and hemorrhage. Although cirrhosis may interfere with production of bile, which contains the bilirubin needed for optimum absorption of vitamin K, the best and quickest manner to counteract the bleeding is to provide vitamin K intramuscularly. Folic acid is a coenzyme with vitamins B 12 and C in the formation of nucleic acids and heme; thus, a deficiency may lead to anemia, not bleeding. Vitamin A deficiency contributes to the development of polyneuritis and beriberi, not hemorrhage.

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer? 1.Vitamin K 2.Oprelvekin 3.Warfarin sodium 4.Protamine sulfate

4 Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.

An adolescent is admitted with an acute hemophilia episode. For what are rest, ice, compression, and elevation most helpful? 1.Encouraging immobilization 2.Decreasing swelling and inflammation 3.Providing pain relief and reducing anxiety 4.Controlling bleeding and retaining joint function

4 Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints. Reducing inflammation is not the goal of treatment for the hemophiliac process. Total immobilization is not required. Pain may be relieved to some degree but is not assured.

1. A nursing intervention with a pt. with lymphoma whose platelet count is 18,000 due to chemo is: - Check all stools for occult blood - Provide oral hygiene every 2 hours - Encourage fluids to 3000ml/day - Check pt.'s temperature every 4 hours

Check all stools for occult blood

1. The nurse is teaching a pt. with thrombocytopenia. Which of the following is appropriate? - Instruct pt. to dab his nose instead of blowing - Instruct pt. to continue with usual activities to prevent DVT - Tell the pt. to be careful when shaving with a razor - Encourage pt. to take aspirin which will mask fever that occurs w/low platelets

Instruct pt. to dab his nose instead of blowing

coagulation studies for warfarin

pt/inr

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? 1.Joints 2.Abdomen 3.Cerebrum 4.Epiphyses

1 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.

1. Based on Virchow's Triad, which patient is at risk for DVT due to endothelial damage? - 70 y/o pt. with severe sepsis - 65 y/o female post-op day 1 after joint replacement surgery - 25 y/o male who uses intravenous drugs - Post-partum pregnant pt.

25 y/o male who uses intravenous drugs

1. A pt. is on heparin drip for DVT L leg. Which lab is a potential complication of heparin therapy? - K 3.6 - Hgb 14.5 - aPTT 65 seconds - Platelets 75,000

Platelets 75,000

A lactating woman has developed thromboembolism. Which drug should be prescribed if she wishes to continue breast-feeding? 1.Aspirin 2.Heparin 3.Dicumarol 4.Phenindione

2 Heparin is the drug of choice to treat thromboembolism in a lactating woman because it is not absorbed in the breast milk. Aspirin may cause severe bleeding so is not preferred. Dicumarol may cause a hemorrhage and therefore is not preferred. Phenindione may cause a bruising effect and therefore is not the drug of choice.

INR therapeutic level

2-3

1. Which of the following interventions is appropriate with treating a child dx hemophilia with hemarthrosis? - Administering Tylenol rectal suppositories prn for pain - Administering the missing blood clotting factors - Administering ibuprofen prn for pain - Administering enoxaparin

Administering the missing blood clotting factors