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 B
Explanation
The nurse must apply knowledge of protein metabolism and hepatic pathophysiology. When blood is digested in the gastrointestinal tract, it serves as a massive protein load. Understanding how the body processes these proteins helps identify specific markers of internal bleeding.
Choice A rationale
Hemoglobin A1c measures average blood glucose levels over the preceding three months. It is used to monitor long-term glycemic control in diabetic patients and does not change in response to acute gastrointestinal bleeding or protein digestion.
Choice B rationale
Blood contains high amounts of protein. When digested, bacteria break down these proteins into ammonia, which the liver normally converts to urea. Elevated BUN, typically 10 to 20 mg/dL, indicates the absorption of blood proteins.
Choice C rationale
Bilirubin levels, normally 0.3 to 1.0 mg/dL, usually increase in cirrhosis due to impaired hepatic processing. Digestion of blood would not cause a decrease in bilirubin; rather, hemolysis or liver failure would typically cause these levels to rise.
Choice D rationale
Chloride is an extracellular anion with a normal range of 98 to 107 mEq/L. Serum chloride levels are primarily affected by acid-base balance and renal function, not by the digestion and absorption of blood in the intestinal tract.
Correct Answer is B
Explanation
A hypophysectomy involves the surgical removal of the pituitary gland. Knowledge of endocrine physiology is required to understand the postoperative loss of posterior pituitary hormones and the necessity of exogenous replacement therapy to maintain fluid balance and prevent complications.
Choice A rationale
Syndrome of inappropriate antidiuretic hormone involves excessive ADH, whereas hypophysectomy results in a total deficiency. Vasopressin is given to prevent the opposite condition, diabetes insipidus, characterized by massive polyuria and severe fluid volume deficit.
Choice B rationale
The posterior pituitary stores and secretes antidiuretic hormone (ADH), also known as vasopressin. Removal of the gland eliminates the body's ability to concentrate urine, necessitating hormonal replacement to regulate water reabsorption in the kidneys.
Choice C rationale
Vasopressin is not primarily used to treat cerebral edema or intracranial pressure. While it affects fluid volume, medications like mannitol or corticosteroids are the standard pharmacological interventions for managing postoperative cerebral swelling and elevated pressure.
Choice D rationale
Vasopressin is an antidiuretic hormone, not a growth hormone. Growth failure is treated with somatropin. While pituitary removal stops growth hormone production, the immediate life-threatening concern postoperatively is the management of massive water loss.
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