Nokea
A client is prescribed an anticoagulant. In which of the following situations would the nurse hold the drug and notify the physician? Select all that apply.
- A. PT exceeds 1.5 times the control value.
- B. PT is less than 1.5 times the control value.
- C. There is evidence of bleeding.
- D. INR is less than 3.0.
- E. INR is greater than 3.0.
Correct Answer: A,C,E
Rationale: The nurse should withhold the drug and contact the physician if any of the following occur: the PT exceeds 1.5 times the control value, there is evidence of bleeding, or the INR is greater than 3.0.
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A nurse is caring for a client prescribed warfarin. The nurse would instruct the client that which of the following foods are high in vitamin K?
- A. Dairy products
- B. Root vegetables
- C. Green leafy vegetables
- D. Fruits and cereals
Correct Answer: C
Rationale: The nurse should inform the client that green leafy vegetables are high in vitamin K, which can affect warfarin's efficacy.
A nurse is conducting an in-service presentation about hemostasis. The nurse determines that the teaching was successful when the class identifies a thrombus as which of the following?
- A. Damage to a blood vessel
- B. Formation of a blood clot
- C. Cessation of bleeding
- D. Coagulation cascade
Correct Answer: B
Rationale: A thrombus refers to the formation of a blood clot, sometimes from damage, in a vessel that impedes blood flow.
Which assessment would the nurse obtain before administering an anticoagulant to a client with DVT? Select all that apply.
- A. Test for a positive Homans' sign.
- B. Examine extremity for skin temperature.
- C. Assess pain.
- D. Assess blood pressure.
- E. Check for pedal pulse.
Correct Answer: A,B,C,E
Rationale: Preadministration assessment for a client with a DVT should include checking for a pedal pulse, examining the extremity for color and skin temperature, assessing for pain, and checking for a positive Homans' sign.
A client is receiving heparin by continuous IV infusion. Which of the following would be most appropriate for the nurse to do?
- A. Perform a complete blood count.
- B. Perform baseline PT/INR.
- C. Perform APTT test 4 to 6 hours after injection.
- D. Perform blood coagulation tests every 4 hours.
Correct Answer: D
Rationale: The nurse should perform blood coagulation tests every 4 hours for the client receiving heparin by continuous IV infusion.
A nurse is reviewing a journal article about antiplatelet agents. Which of the following would the nurse expect to be discussed? Select all that apply.
- A. Heparin
- B. Warfarin
- C. Abciximab
- D. Anagrelide
- E. Dipyridamole
Correct Answer: C,D,E
Rationale: Abciximab, anagrelide, and dipyridamole are antiplatelet agents. Heparin and warfarin are anticoagulants.