NSG 210 Clotting Questions With Correct Answers Latest Edition
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Course
NSG 210
Institution
NSG 210
NSG 210 Clotting
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
a...
NSG 210 Clotting
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein
thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level
drops to 110,000/µL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH). - ANS: B. Discontinue the heparin infusion.
All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive
heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The
platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions
increase the risk for thrombosis.
Which intervention will be included in the nursing care plan for a patient with immune
thrombocytopenic purpura (ITP)?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion. - ANS: B. Avoid intramuscular (IM) injections.
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can
be used for oral care. There is no need to restrict activity or place the patient in a private room.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-
induced thrombocytopenia (HIT)?
,a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time - ANS: D. Activated partial thromboplastin time
Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time
will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not
be affected by HIT.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain
and swelling in the right knee. The nurse should
a. Apply heat to the knee.
b. Immobilize the knee joint.
c. Assist the patient with light weight bearing.
d. Perform passive range of motion to the knee. - ANS: B. Immobilize the knee joint.
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease
bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the
bleeding stops, ROM and physical therapy are started.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate
immediately to the health care provider?
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient's back. - ANS: B. The patient is difficult to arouse.
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and
requires immediate action. The other information should be documented and reported but would not
be unusual in a patient with thrombocytopenia.
, The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with
blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed
assistive personnel (UAP)?
a. Verify the patient identification (ID) according to hospital policy.
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion. - ANS: B. Obtain the
temperature, blood pressure, and pulse before the transfusion.
UAP education includes measurement of vital signs. UAP would report the vital signs to the registered
nurse (RN). The other actions require more education and a larger scope of practice and should be done
by licensed nursing staff members.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever,
headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what
action should the nurse take?
a. Give the PRN diphenhydramine .
b. Send a urine specimen to the laboratory.
c. Administer PRN acetaminophen (Tylenol).
d. Draw blood for a new type and crossmatch. - ANS: C. Administer PRN acetaminophen (Tylenol).
The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The
transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen
is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions.
This type of reaction does not indicate incorrect crossmatching.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after
a transfusion of packed red blood cells is started. The nurse's first action should be to
a. Administer oxygen therapy at a high flow rate.
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