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 C
Explanation
Educating a patient with atrial fibrillation requires applying knowledge of cardiac hemodynamics and the coagulation cascade. The nurse must focus on how ineffective atrial contractions lead to blood stasis, increasing the probability of clot formation and subsequent systemic embolization.
Choice A rationale
Atrial fibrillation does not directly cause hyperglycemia. While the stress of an acute arrhythmia might slightly elevate blood glucose due to cortisol release, it is not a primary complication or a major risk specifically linked to this rhythm.
Choice B rationale
Diabetic retinopathy is a microvascular complication resulting from chronic poor glucose control over many years. It is not exacerbated or caused by the onset of atrial fibrillation, which is a macrovascular and electrical conduction issue of the heart.
Choice C rationale
In atrial fibrillation, the atria quiver instead of contracting effectively, allowing blood to pool in the left atrial appendage. This stasis leads to thrombus formation; if a clot dislodges, it can travel to the brain.
Choice D rationale
Diabetic ketoacidosis is typically triggered by infection, insulin omission, or extreme physiological stress in Type 1 diabetics. While an arrhythmia is a stressor, the most specific and dangerous direct risk of atrial fibrillation remains systemic thromboembolism
Correct Answer is B
Explanation
End-of-life care involves applying principles of bereavement support and cultural sensitivity. Knowledge of post-mortem care and therapeutic communication is necessary. Providing a respectful environment for the family to process their loss is a core nursing responsibility in the hospice setting.
Choice A rationale
. Dismissing visitors due to being busy violates the core tenets of hospice care and bereavement support. The needs of the family are a priority following the death of a patient. Nurses must manage time to allow for family grieving and closure.
Choice B rationale
. Allowing the family to view the body in the room provides a private, familiar, and dignified setting for saying goodbye. This action supports the grieving process and is a standard of care. The room should be prepared to appear peaceful.
Choice C rationale
. Moving the body to the morgue before the family arrives is impersonal and can be distressing. The clinical environment of a morgue is not conducive to healthy grieving. Most facilities allow a period of viewing in the room first.
Choice D rationale
. Telling the family not to come is ethically inappropriate and emotionally harmful. Family presence at the time of death or shortly after is a critical component of the mourning process. Hospice philosophy emphasizes support for the entire family unit..
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