Olivia McRitchie
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NCLEX (Medical-Surgical) Nursing Test sobre Chapter 16.4: Deep Venous Thrombosis, creado por Olivia McRitchie el 02/10/2018.

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Olivia McRitchie
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Chapter 16.4: Deep Venous Thrombosis

Pregunta 1 de 13

1

Select the patient that would NOT be at risk of getting DVT.

Selecciona una de las siguientes respuestas posibles:

  • A 65-year-old female that just got out of a hip arthroplasty.

  • A 70-year-old female that has experienced a hip fracture.

  • A 49-year-old male with atrial fibrillation.

  • A 50 year-old male that has just had an MI after having a history of angina.

  • An 81-year-old female that has had an ischemic stroke and is paralyzed on her right side.

  • A 25-year-old back on oral contraceptives after giving birth 3 months prior.

  • A 50 year old with restrictive cardiomyopathy, but no noticeable activity intolerance.

Explicación

Pregunta 2 de 13

1

You have a male post-knee arthroplasty patient that you are about to release back home. His wife is going to be the primary caregiver, so you are performing education on what the signs of DVT are. Which of the following statements made by the wife shows that she understands the teaching you have given?

Selecciona una de las siguientes respuestas posibles:

  • "I should call my husband's doctor if he starts to have a dull, aching pain in either of his calves when he walks."

  • "I should not worry about tenderness, swelling, warmth, and redness in his leg. That is a normal part of healing after a knee replacement."

  • "I should wait until I see that the affected leg is blue-tinted and swelling before I call his doctor."

  • "DVT does not have many serious complications; it is simply uncomfortable."

Explicación

Pregunta 3 de 13

1

Match the diagnostic test with its correct description:

: Used to visualize vein and measure velocity of blood flow in the veins. Although the clot cannot be visualized, its presence can be inferred by an inability to compress the vein during examination.

: Most accurate diagnostic tool for venous thrombosis. A contrast medium is injected to assess the location and extent of venous thrombosis.

A noninvesive test that measures changes in blood flow through the veins. It is often used with Doppler ultrasonography. It is particularly useful in diagnosing thromboses of larger or superficial veins.

: A noninvesive test that is particularly useful in a thrombosis of the venae cavae or pelvic veins is suspected.

Arrastra y suelta para completar el texto.

    Duplex venous ultrasonography
    Doppler ultrasound
    Ascending contrast venography
    Plethysmography:
    Magnetic resonance imaging
    Positron emission tomography
    X-ray

Explicación

Pregunta 4 de 13

1

Heparin is an anticoagulant that interferes with the clotting cascade by inhibiting thrombin and preventing the conversion of fibrinogen to fibrin. If used at therapeutic levels, it prolongs thrombin time, clotting time, and aPTT. If given IV, it works immediately; if given SQ, it takes under an hour to work. It should be given frequently or continually because it has a short biological half-life.

Select the nursing considerations for this drug (7 of these are right).

Selecciona una o más de las siguientes respuestas posibles:

  • Assess patient history for unexplained or active bleeding.

  • Give a test dose to all patients.

  • If giving SQ, administer in abdominal sites, but not within 2 inches of the umbilicus.

  • Do not aspirate prior to injecting or massage the site after the injection.

  • IV solutions can only be diluted with normal saline. Be sure to give with an infusion pump.

  • Keep protamine sulfate nearby to reverse effects of drug.

  • Monitor and report lab values outside of therapuetic range.

  • Promptly report bloody vomit, bloody urine, bleeding gums, or unexplained abdomen or back pain.

  • Do not give the drug during pregnancy.

  • Be vigilant for signs of heparin-induced thrombocytopenia.

Explicación

Pregunta 5 de 13

1

Which of the following is NOT proper patient and family teaching for this female patient on heparin?

Selecciona una de las siguientes respuestas posibles:

  • Report unusual bleeding, including heavy menstrual bleeding.

  • Use an electric razor and soft bristled toothbrush.

  • Prevent injuries the best you can by utilizing nightlights and keeping clear pathways in your house.

  • Avoid contact sports, such as football and soccer.

  • Eat plenty of yellow and dark green vegetables.

  • If you are in pain and considering taking an over the counter pain medication, take Tylenol, NOT Motrin, Advil, Aleve, Naprosyn, or Aspirin.

  • Wear a medical alert tag and alert all healthcare personnel of heparin therapy,

Explicación

Pregunta 6 de 13

1

Low molecular weight heparins provide a more precise and predictable anticoagulant effect than unfractionated heparins. They prevent the conversion of prothrombin to thrombin, liberation of thromboplastin from platelets, and formation of a stable clot.

Which of the following is INCORRECT about low molecular weight heparins?

Selecciona una de las siguientes respuestas posibles:

  • Low molecular weight heparins are interchangeable with each other, but not with unfractionated heparin.

  • The risk of heparin-induced thrombocytopenia is significantly lower, but if a client was previously treated with an unfractionated heparin, HIT may still develop.

  • The nurse should assess for evidence of active bleeding, a history of bleeding disorders and/or thrombocytopenia, or sensativity to heparin or sulfites.

  • The nurse should be aware that PT and aPTT levels may still be within normal levels even if hemorrhage is occurring.

  • The nurse should be be vigilant for unusual or masked bleeding.

  • Administer SQ injections into abdominal wall, thigh, or butt, and make sure you rotate sites,

  • Do not aspirate or massage when you inject drug.

Explicación

Pregunta 7 de 13

1

Select the PROPER patient teaching to give to a patient on a low-molecular weight heparin.

Selecciona una de las siguientes respuestas posibles:

  • Teach patient to self-inject into different sites each injection, then rub injection site.

  • Excessive bruising and bleeding is normal for this type of drug.

  • Unlike with unfractionated heparins, it is safe to take NSAIDs with this drug.

  • Report chest pain, difficulty breathing, itching, rash, or swelling to your healthcare provider.

Explicación

Pregunta 8 de 13

1

Warfarin interferes with the synthesis of vitamin-K dependent clotting factors by the liver. It has no effect on already circulating clotting factors or on existing clots. It does, however, inhibit the extension of existing thrombi and the formation of new clots. Its action is cumulative & more prolonged than heparin.

Select the nursing considerations for this drug.

Selecciona una o más de las siguientes respuestas posibles:

  • Assess lab results and history for evidence of bleeding.

  • Check all drugs the patient is on for interactions with warfarin.

  • Inform women of childbearing age that that they should tell their doctor if they are pregnant or trying to become pregnant.

  • Do not crush oral tablets.

  • Drug should be given with a meal.

  • Dilute IV solutions with dextrose, normal saline, or Ringer's solution and administer within 4 hours by direct IV at rate of 25 mg/min.

  • Keep vitamin K available to reverse effects in the event of excessive bleeding or hemorrhage.

  • Monitor PT and INR and report results outside of therapeutic range.

Explicación

Pregunta 9 de 13

1

Which of the following is inappropriate teaching to give to a patient on warfarin?

Selecciona una de las siguientes respuestas posibles:

  • If you experience bloody vomit, urine, or feces; excessive bleeding gums; excessive bruising; or anything else that could indicate excessive bleeding, skip dose and contact provider.

  • Report rash, dark urine, and yellowing of your skin or eyes, as these can be signs of hepatitis.

  • It is okay to substitute a name brand for a genetic, or one brand for another brand.

  • Take drug at the same time every day,

  • Contact your doctor if you think you are pregnant.

  • Use a soft-bristle toothbrush and electric razors, make sure your wear shoes, and keep a night light and clear walking path, as these things can prevent injury and bleeding.

  • Do not smoke or drink, and call your doctor before taking any OTC drugs.

  • Notify all healthcare personnel of warfarin therapy.

  • Wear a medical alert tag.

Explicación

Pregunta 10 de 13

1

Frequent monitoring of the infusion pump during anticoagulation therapy is an important nursing responsibility.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 11 de 13

1

Selecciona la opción correcta de los menús desplegables para completar el texto.

Anticoagulation is initiated with unfractionated or LMW heparin. The initial IV bolus should consist of ( 7,500-10,000 units, 1,000-1,500 IU, 5,000-10,000 units, 10,000-20,000 units ) of unfractionated heparin, then the continuous heparin infusion should be at ( 1,000-1,500 IU, 7,500-10,000 units, 500-1,000 IU, 2,000-3,000 IU ) per hour (IU standing for "international units"). The dosage is calculated to maintain the ( aPTT, PT, INR ) at approximately ( twice, three times ) the normal value. An infusion pump is used to deliver the prescribed dosage.

LMW heparins are increasingly used to prevent and treat venous thrombosis. They do not require the close lab monitoring of unfractionated heparins. These heparins are administered ( subcutaneously, instramuscularly, subdermally ) in fixed doses, QD or BID, which allows outpatient treatment. These types of heparins are also more effective and carry lower risks for ( bleeding and thrombocytopenia, excessive bleeding, excessive menstrual bleeding, thrombocytopenia ).

Warfarin may be initiated with heparin therapy. Overlapping therapy for ( 4-5 days, 4-5 weeks, 4 weeks, 5 weeks ) is important because the full anticoagulant effect of warfarin is delayed, and warfarin may actually promote clotting during the first few days of therapy. Warfarin doses are adjusted to maintain the INR at ( 2.0-3.0, 1.0-2.0, 3.0-4.0, 4.0-5.0 ). Once the INR has been achieved, ( heparin, warfarin ) is discontinued and a maintenance dose of ( warfarin, heparin ) is prescribed.

Anticoagulation will generally be continued for at least ( 3 months, 3 weeks, 6 months, 1 year ). When DVT recurs or risk factors are present, anticoagulant therapy may be prolonged. Regular follow ups are necessary to be sure INR remains within the desirable range.

Explicación

Pregunta 12 de 13

1

You have a 61-year-old patient that is presenting with a thrombosis in her deep femoral vein. She has already been placed on a LMW heparin. She is concerned that the DVT will not go away, and she is incredibly uncomfortable. What else can be done to help this patient? (3 of these are right).

Selecciona una o más de las siguientes respuestas posibles:

  • "If the heparin does not work, doctors can perform surgery to remove the blood clot."

  • "Since your DVT is in your femoral vein, we can insert a Greenfield filter to trap it so it doesn't reach your lungs and become a pulmonary embolism."

  • "I can apply a warm, moist compress over your femoral vein."

  • "We can elevate you legs 15-20 degrees, with your knees slightly flexed above the level of your heart."

  • "We can give you elastic antiembolism socks."

  • "You should probably avoid walking, but it's a good idea for you to perform leg exercises."

Explicación

Pregunta 13 de 13

1

You have a 71-year-old male post-knee replacement surgery. He has a history of hemphilia type B, so doctors deemed it unsafe to give him anticoagulants. Despite the usage of elastic antiembolism stockings and the history of hemophilia, the patient still develops a thrombus in his left popliteal vein. The patient can ambulate, but only very briefly and not for very long distances. He last reported his pain to be a 6/10.

What are appropriate interventions for this patient?

Selecciona una o más de las siguientes respuestas posibles:

  • Obtain a baseline calf measurement, mark where you measured his calf, and then measure his calf every day.

  • Assess pain location, characteristics, and level when you take the rest of vitals,

  • Apply warm, moist heat to his left popliteal vein once a day.

  • Assess the skin of his left leg and foot every time you assess vitals.

  • Keep the legs elevated at 15-20 degrees at all times.

  • Wash the patient's thrombosis with a soap that the patient brought from home.

  • Encourage position changes once every 4 hours.

  • Encourage active ROM exercises at least every 8 hours and try to ambulate the patient at least once a day, as long as is tolerated.

  • Encourage deep breathing and coughing.

  • Encourage a fluid intake of at least 2,500 mL/day and increased fiber intake.

Explicación

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