Hesi Deep Vein Thrombosis With Questions
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?
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?
3. Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT?
A. Measure calf circumference bilaterally
Venous Ultrasound or Doppler studies
non invasic and provide evidence of a venous obstruction by a thrombus.
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.
4. Which route of administration should the nurse anticipate for this treatment?
5. If pharamcologic therapy is initiated, which lab value would indicate to the nurse that heparinization have been reached?
B. APTT 65 seconds, control 35 seconds
APTT (Activated Partial Thromboplastin Time)
Remember to reflect therepeutic heparinization, the APTT should be 1.5-2 times greater than the control value in seconds.
PT/INR Prothrombin Time/ International Normalized RatioRemember to reflect a therapeutic level of warfarin (Coumadin) the PT should be 1.5-2 times the control value in seconds and INR should be 2-3.
6. What is the correct IV bolus dose of heparin?
7. At what rate should the IV pump be set to deliver the prescribed rate of infusion?
8. Which action should the nurse expect to initiate?
C. Decrease the rate of infusion
9. Which action should the nurse initiate first?
B. Stop the heparin infusion
10. Which medication will be administered?
B. Protamine sulfate
11. Which description best identifies the purpose of an adverse occurence or incident report?
C. Hospital record that helps track patterns of risk to guide corrective action
12. What is the legal concern involved in this situation?
13. Which nursing diagnosis should the nurse give the highest priority when planning care for Mrs. Adams?
B. Risk for injury (bleeding) related to anticoagulant therapy
14. Which nursing intervention should the nurse implement to help reduce the risk for abnormal bleeding during heparin therapy.
D. Maintain heparin on a continuous infusion pump
15. Which nursing interventions will reduce pain related to decreased venous flow?
B. Elevate the affected leg
E. Apply warm comress
16. Which action can be delegated by the nurse to an unlicensed assistive personnel who is assigned to the nurse caring for Mrs. Adams
A. Obtain stool specimen for guaiac
17. Which communication is best for the nurse to use with the UAP?
C. “I’ve noticed that Mrs. Adams’ stool specimen was not obtained”
18. Which action should the nurse implement first?
A. Administer oxygen
19. Which decision is most appropriate for the nurse to make regarding the administration of low dose morphine at this time?
C. The dose should be given since morphine reduces pain and anxiety
20. Which food should the nurse instruct Mrs. Adams to avoid?
Green leafy vegetables
21. Mrs. Adams should also be instructed to avoid which OTC product?
22. What is the best response by the nurse?
“You seem to be feeling pretty overwhelmed right now”
23. Based on the findings, which action should the nurse implement?
A. Continue with discharge teaching
24. Which action should be implemented during the administration of low-molecular weight heparin?
B. Use subcutaneous sites in the abdomen