Hesi Deep Vein Thrombosis With Questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
1. Which term should the nurse use to most accurately report that Mrs. Adams may have developed a clot in her vein that is causing her pain and the swelling in her leg?
answer
D. Thrombophlebitis
question
The nurse knows that there are 3 major factors involved in the development of DVT. There 3 factors are referred to as Virchow's triad and include: Stasis of blood, vessel wall injury, and altered blood coagulation. 2. Which of the medications taken by Mrs. Adams places her at increased risk for the development of DVT?
answer
Oral Contraceptives
question
3. Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT?
answer
A. Measure calf circumference bilaterally
question
Venous Ultrasound or Doppler studies
answer
non invasic and provide evidence of a venous obstruction by a thrombus.
question
Venography/ Venogram
answer
involves the injection of a radio-contrast medium into the venous system of the lower extemities. X-ray films taken will then allow visualization of any obstruction in the venous circulation. Nursing Implications include assessment of allergies to iodine and adequate renal function. Requires informed consent and pre-procedure hydration. Post-procedure nurse assesses the insertion site, monitors vital signs, and provides adequate hydration.
question
4. Which route of administration should the nurse anticipate for this treatment?
answer
D. Intravenous
question
5. If pharamcologic therapy is initiated, which lab value would indicate to the nurse that heparinization have been reached?
answer
B. APTT 65 seconds, control 35 seconds
question
APTT (Activated Partial Thromboplastin Time)
answer
Remember to reflect therepeutic heparinization, the APTT should be 1.5-2 times greater than the control value in seconds.
question
6. What is the correct IV bolus dose of heparin?
answer
6.80 ml
question
7. At what rate should the IV pump be set to deliver the prescribed rate of infusion?
answer
34
question
8. Which action should the nurse expect to initiate?
answer
C. Decrease the rate of infusion
question
9. Which action should the nurse initiate first?
answer
B. Stop the heparin infusion
question
10. Which medication will be administered?
answer
B. Protamine sulfate
question
11. Which description best identifies the purpose of an adverse occurence or incident report?
answer
C. Hospital record that helps track patterns of risk to guide corrective action
question
12. What is the legal concern involved in this situation?
answer
D. Malpractice
question
13. Which nursing diagnosis should the nurse give the highest priority when planning care for Mrs. Adams?
answer
B. Risk for injury (bleeding) related to anticoagulant therapy
question
14. Which nursing intervention should the nurse implement to help reduce the risk for abnormal bleeding during heparin therapy.
answer
D. Maintain heparin on a continuous infusion pump
question
15. Which nursing interventions will reduce pain related to decreased venous flow?
answer
B. Elevate the affected leg E. Apply warm comress
question
16. Which action can be delegated by the nurse to an unlicensed assistive personnel who is assigned to the nurse caring for Mrs. Adams
answer
A. Obtain stool specimen for guaiac
question
17. Which communication is best for the nurse to use with the UAP?
answer
C. "I've noticed that Mrs. Adams' stool specimen was not obtained"
question
18. Which action should the nurse implement first?
answer
A. Administer oxygen
question
19. Which decision is most appropriate for the nurse to make regarding the administration of low dose morphine at this time?
answer
C. The dose should be given since morphine reduces pain and anxiety
question
20. Which food should the nurse instruct Mrs. Adams to avoid?
answer
Green leafy vegetables
question
21. Mrs. Adams should also be instructed to avoid which OTC product?
answer
Acetaminophen (Tylenol)
question
22. What is the best response by the nurse?
answer
"You seem to be feeling pretty overwhelmed right now"
question
23. Based on the findings, which action should the nurse implement?
answer
A. Continue with discharge teaching
question
24. Which action should be implemented during the administration of low-molecular weight heparin?
answer
B. Use subcutaneous sites in the abdomen
