The nurse reviews the medical records for a 68-year-old client who had a right Total Hip Arthroplasty (THA) 2 days ago. A diagnosis of a sub-massive pulmonary embolism (PE) is confirmed via computed tomography pulmonary angiography (CTPA). The nurse revises the plan of care to include nursing actions related to drug therapy. Which of the following nursing actions are indicated for a client receiving anticoagulation therapy for a pulmonary embolism?
Monitor the client's activated partial thromboplastin time.
Check for the availability of protamine sulfate.
Monitor the client's international normalized ratio.
Monitor the client's hematocrit and platelet levels.
Check for the availability of phytonadione.
Assess the client for signs of bleeding or bruising.
Correct Answer : A,B,C,D,E,F
The scenario requires applying knowledge of anticoagulation pharmacology and safety protocols for pulmonary embolism management. Nurses must monitor therapeutic levels, maintain reversal agents, and assess for complications like bleeding to ensure systemic stability and prevent further clot propagation during recovery.
Choice A rationale
Activated partial thromboplastin time measures the intrinsic pathway of coagulation. It is vital for monitoring unfractionated heparin therapy, with a normal range of 30 to 40 seconds. Prolonged values indicate a higher risk for spontaneous hemorrhage.
Choice B rationale
Protamine sulfate acts as a specific antagonist to neutralize the anticoagulant effects of heparin. Availability is critical for immediate reversal if life threatening bleeding occurs or if the activated partial thromboplastin time exceeds the safe therapeutic range.
Choice C rationale
The international normalized ratio assesses the extrinsic pathway, primarily for warfarin therapy. A normal range for healthy individuals is 0.8 to 1.2, but therapeutic targets for pulmonary embolism typically fall between 2.0 and 3.0.
Choice D rationale
Hematocrit and platelet levels indicate bone marrow function and blood volume. Significant drops in hematocrit suggest internal bleeding, while platelet monitoring is essential to detect heparin induced thrombocytopenia, a serious immune mediated complication of anticoagulant use.
Choice E rationale
Phytonadione, or Vitamin K, is the essential reversal agent for warfarin induced anticoagulation. It promotes the hepatic synthesis of clotting factors 2, 7, 9, and 10, effectively counteracting excessive anticoagulation and reducing the risk of hemorrhage.
Choice F rationale
Continuous physical assessment is necessary to identify early signs of coagulopathy. These include petechiae, ecchymosis, hematuria, or bleeding gums. Early detection allows for prompt dosage adjustments or the administration of reversal agents to prevent clinical deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
End-of-life care focuses on communication, psychological support, and advocacy. Knowledge of therapeutic communication and the stages of grief is required to provide holistic care that empowers the family while reducing the uncertainty and helplessness often associated with terminal illness.
Choice A rationale
Clarifying rationale reduces anxiety by providing the family with an understanding of how pain management promotes comfort. Knowledge of pharmacokinetics helps families accept that scheduled dosing prevents breakthrough pain, reducing their stress regarding the dying process.
Choice B rationale
Using the teach-back method ensures that the family accurately understands the complex medical information provided. This reduces frustration caused by misunderstandings or the cognitive impairment often associated with high stress and emotional exhaustion during terminal care.
Choice C rationale
Transparency regarding delays prevents feelings of neglect or abandonment. Explaining the medical reasoning behind schedule changes builds trust and ensures the family feels respected and involved in the care planning process during a vulnerable time.
Choice D rationale
Limiting interactions can make a family feel isolated or ignored during a crisis. While privacy is important, the nurse must remain available and present, as social isolation often increases the stress and fear associated with death.
Choice E rationale
Providing unlimited access to staff addresses the unpredictability of terminal illness and the family's need for reassurance. This support system minimizes frustration by ensuring that questions and physiological changes are addressed promptly by the healthcare team.
Correct Answer is ["7"]
Explanation
Step 1 is 350 mg ÷ 250 mg × 5 mL.
Step 2 is 1.4 × 5 mL.
Step 3 is 7 mL.
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