A nurse is caring for a client who has deep vein thrombosis and is receiving enoxaparin therapy subcutaneously once daily at home. The nurse should instruct the client to report which of the following findings immediately?
Bruising at injection site
Redness at injection site
Swelling in one leg
Mild pain at injection site.
The Correct Answer is C
This is because swelling in one leg could indicate a new or worsening deep vein thrombosis (DVT), which is a serious condition that can lead to pulmonary embolism or other complications. The client should report this finding to the provider immediately and seek medical attention.
Choice A) Bruising at injection site is wrong because bruising is a common and expected side effect of enoxaparin therapy, especially if the client is using the same injection site repeatedly.
The client should be instructed to rotate the injection sites and apply gentle pressure after each injection to minimize bruising.
Choice B) Redness at injection site is wrong because redness is also a common and expected side effect of enoxaparin therapy, as it indicates a local inflammatory response to the medication.
The client should be advised to avoid rubbing or scratching the injection site and to apply a cold compress if needed.
Choice D) Mild pain at injection site is wrong because mild pain is also a common and expected side effect of enoxaparin therapy, as it reflects the needle insertion and the medication delivery.
The client should be reassured that the pain will subside shortly and to use a different injection site for the next dose.
Normal ranges for enoxaparin therapy are based on the client’s weight, indication, and renal function.
The usual dose for DVT prophylaxis is 40 mg subcutaneously once daily, and the usual dose for DVT treatment is 1 mg/kg subcutaneously every 12 hours.
The client should have regular blood tests to monitor the anti-factor Xa level, which should be between 0.5 and 1.0 IU/mL for DVT prophylaxis and between 0.6 and 1.0 IU/mL for DVT treatment.
The client should also have regular platelet counts to check for heparin-induced thrombocytopenia (HIT), which is a rare but serious complication of enoxaparin therapy that causes a drop in platelets and an increased risk of thrombosis.
The normal platelet count range is 150,000 to 450,000/mm3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A) Activated partial thromboplastin time (aPTT).This is because aPTT is the most commonly used laboratory test to monitor the therapeutic effect of heparin therapy.
Heparin is an anticoagulant that inhibits the formation of thrombin and fibrin, which are essential for blood clotting.Heparin therapy is indicated for the treatment of deep vein thrombosis (DVT), which is a condition where blood clots form in the deep veins of the legs or pelvis.
Choice B) Prothrombin time (PT) is wrong because PT is used to monitor the therapeutic effect of warfarin therapy, not heparin therapy.
Warfarin is another anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors.Warfarin therapy is also indicated for the treatment of DVT, but it has a different mechanism of action and monitoring than heparin therapy.
Choice C) International normalized ratio (INR) is wrong because INR is a standardized way of reporting PT results that accounts for the variability of different laboratory methods.INR is also used to monitor the therapeutic effect of warfarin therapy, not heparin therapy.
Choice D) Platelet count is wrong because platelet count is not directly affected by heparin therapy.However, platelet count should be monitored periodically in patients receiving heparin therapy to detect heparin-induced thrombocytopenia (HIT), which is a rare but serious complication of heparin therapy that causes a drop in platelet count and an increased risk of thrombosis.
Choice E) Hemoglobin is wrong because hemoglobin is not directly affected by heparin therapy.However, hemoglobin should be monitored periodically in patients receiving heparin therapy to detect bleeding complications, which are the most common adverse effects of heparin therapy.
The normal range for aPTT is 25 to 35 seconds, but the therapeutic range for heparin therapy is usually 1.5 to 2.5 times the normal range, depending on the indication and protocol.
The normal range for PT is 11 to 13 seconds, and the therapeutic range for warfarin therapy is usually an INR of 2 to 3, depending on the indication and protocol
Correct Answer is ["A","D"]
Explanation
A patient with a high aPTT result is at risk for bleeding, so assessing for signs and symptoms of bleeding is important.
Holding heparin therapy per protocol is also appropriate, as heparin is the cause of the prolonged aPTT.
The other choices are wrong because:
• Choice B is wrong because continuing heparin therapy at the current rate will increase the risk of bleeding and further prolong the aPTT.
• Choice C is wrong because decreasing heparin therapy per protocol is not enough to reverse the effects of heparin.
Heparin should be stopped until the aPTT returns to the therapeutic range.
• Choice E is wrong because increasing heparin therapy per protocol will worsen the situation and cause more bleeding and coagulation problems.
The normal range for aPTT is 25 to 35 seconds, and the therapeutic range for heparin therapy is 60 to 80 seconds.A result of 90 seconds indicates excessive anticoagulation and increased bleeding risk.
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