Nokea
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.
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Protamine is used to treat overdose of which of the following medications? Select all that apply.
- A. Clopidogrel (Plavix)
- B. Heparin
- C. Enoxaparin (Lovenox)
- D. Alreplase (Activase)
- E. Warfarin (Coumadin)
Correct Answer: B,C
Rationale: Protamine is used to treat overdose of heparin and low-molecular-weight heparins (LMWHs).
A female client is receiving an anticoagulant to prevent the formation and extension of blood clots. What instruction should the nurse include in the teaching plan for the client?
- A. Avoid caffeinated drinks.
- B. Take the drug on an empty stomach.
- C. Use a reliable contraceptive.
- D. Take the drug with a glass of milk.
Correct Answer: C
Rationale: The nurse should instruct the female client to use a reliable contraceptive to prevent pregnancy, as anticoagulants can pose risks during pregnancy.
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 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.
The nurse instructs a client receiving warfarin about the importance of consistent intake of dietary vitamin K to decrease fluctuations in PT/INR. The nurse determines that the client understands the instructions when he identifies which foods as containing vitamin K? Select all that apply.
- A. Broccoli
- B. Cauliflower
- C. Fish
- D. Yogurt
- E. Chicken
Correct Answer: A,B,C,D
Rationale: Foods high in vitamin K include leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt.