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
Explanation
Acute stroke management requires rapid application of the time-is-brain principle. Knowledge of the differential diagnosis between ischemic and hemorrhagic strokes is vital. Practitioners must prioritize diagnostic imaging that safely identifies hemorrhage to determine if thrombolytic therapy is indicated.
Choice A rationale
A non-contrast CT scan is the gold standard for initial stroke assessment to rule out intracranial hemorrhage. It is faster than an MRI and avoids contrast, which can mimic blood or cause kidney injury in emergencies.
Choice B rationale
Contrast is avoided during the initial emergency scan because it can leak into brain tissue and appear hyperdense. This mimics the appearance of acute blood, making it difficult to distinguish between a bleed and ischemia.
Choice C rationale
Thrombolytics cannot be administered until a CT scan confirms the absence of a hemorrhage. Giving these drugs to a patient with a brain bleed would cause catastrophic worsening of the condition and potential death.
Choice D rationale
While IV access and hydration are important, they are secondary to identifying the type of stroke. Diagnostic imaging must occur first to facilitate the most time-sensitive treatments like fibrinolysis or mechanical thrombectomy for ischemia.
Correct Answer is A
Explanation
Pulmonary embolism disrupts the ventilation-perfusion ratio, leading to sudden hypoxemia and respiratory distress. Prioritizing interventions requires applying the airway, breathing, circulation framework. Knowledge of gas exchange and emergency protocols is necessary to stabilize the client and maintain systemic cellular oxygenation.
Choice A rationale
Oxygen administration is the priority to treat hypoxemia caused by the physiological dead space created by the embolism. Improving arterial oxygen saturation supports myocardial and cerebral function while reducing the workload of the right ventricle during obstruction.
Choice B rationale
Morphine acts as an analgesic and vasodilator which can reduce anxiety and preload. However, it does not address the primary physiological threat of impaired gas exchange. Breathing and oxygenation must be stabilized before managing pain or sedation.
Choice C rationale
Cardiac monitoring identifies arrhythmias and right-sided heart strain associated with pulmonary hypertension. While diagnostic, it is a secondary action that follows the restoration of oxygenation. Assessment tools should not delay the implementation of life-saving oxygen therapy.
Choice D rationale
Lactated Ringer's is used for volume expansion and electrolyte replacement. In pulmonary embolism, excessive fluid can worsen right ventricular failure and pulmonary edema. Circulatory support is important but remains secondary to correcting the immediate life-threatening respiratory deficit..
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