Nursing Interventions for DVT and PE Prevention
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is caring for a postpartum patient who is at risk for developing DVT.
Which of the following interventions should the nurse implement to prevent DVT? (Select all that apply.).
Explanation
These are the interventions that can help prevent DVT by keeping the blood flowing and preventing clot formation.
Choice D is wrong because massaging the affected limb can dislodge a clot and cause a PE.Choice E is wrong because elevating the affected limb can reduce blood flow and increase the risk of DVT.
Normal ranges for DVT prevention vary depending on the individual risk factors and clinical situation, but some general recommendations are:
• Encourage early and frequent ambulation as soon as possible after delivery.
• Apply anti-embolism stockings or intermittent pneumatic compression devices during hospital stay and until fully mobile.
• Administer prophylactic anticoagulant medication as prescribed, usually for 6 to 12 weeks postpartum or longer if high risk.The type and dose of anticoagulant may depend on the patient’s weight, renal function, breastfeeding status and preference.
A nurse is reviewing the laboratory results of a client who has DVT and is receiving unfractionated heparin IV.
Which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of heparin therapy?
Explanation
Activated partial thromboplastin time (aPTT).The aPTT test is used to monitor the effectiveness of heparin therapy in clients with DVT.Heparin works by inhibiting the formation of blood clots by blocking the activity of clotting factors.The aPTT test measures the time it takes for a clot to form in a sample of blood after substances that cause clotting have been added.The normal range for aPTT is 30-40 seconds.
Prothrombin time (PT) is used to monitor warfarin therapy, not heparin therapy.
International normalized ratio (INR) is used to monitor warfarin therapy, not heparin therapy.
D-dimer is used to diagnose DVT, not monitor heparin therapy.
A nurse is teaching a client who has DVT and is prescribed warfarin.
The nurse should instruct the client to avoid fluctuations in the amount and frequency of consumption of which of the following foods?
Explanation
Spinach.The nurse should instruct the client to avoid fluctuations in the amount and frequency of consumption of foods that are rich in vitamin K, such as spinach, because they can make warfarin less effective.Vitamin K is involved in blood clotting and can counteract the anticoagulant effect of warfarin.
Grapefruit is wrong because grapefruit can increase the risk of bleeding by affecting warfarin metabolism or pharmacodynamics.Grapefruit can inhibit the enzyme CYP3A4 that metabolizes warfarin and increase its blood levels.
Cheese is wrong because cheese does not have a significant interaction with warfarin.However, some types of cheese, such as mature cheese and blue cheese, contain small amounts of vitamin K and should be consumed consistently.
Eggs is wrong because eggs do not have a significant interaction with warfarin.However, egg yolks contain some vitamin K and should be consumed consistently.
A nurse is assessing a client who has DVT and reports sudden onset of dyspnea and chest pain.
The nurse should suspect that the client has developed which of the following complications?
Explanation
Pulmonary embolism.A pulmonary embolism is a condition in which a blood clot blocks an artery in the lung, preventing blood flow to part of the lung.A pulmonary embolism can be a complication of deep vein thrombosis (DVT), which is a condition in which a blood clot forms in a deep vein, usually in the leg.If the clot breaks off and travels to the lung, it can cause a pulmonary embolism.The symptoms of a pulmonary embolism include sudden onset of dyspnea (difficulty breathing) and chest pain, which may worsen with coughing or deep breathing.
Heart failure is wrong because heart failure is a condition in which the heart cannot pump enough blood to meet the body’s needs.Heart failure can cause dyspnea and chest pain, but it is usually a chronic condition that worsens over time, not a sudden onset event.
Pneumonia is wrong because pneumonia is an infection that inflames the air sacs in the lungs, causing them to fill with fluid or pus.
Pneumonia can cause dyspnea and chest pain, but it also causes other symptoms such as fever, cough, and sputum production.Pneumonia usually develops gradually, not suddenly.
Pericarditis is wrong because pericarditis is an inflammation of the sac that surrounds the heart, called the pericardium.
Pericarditis can cause chest pain, but it is usually sharp and stabbing, and it changes with body position or breathing.
Pericarditis can also cause fever, fatigue, and palpitations.
Pericarditis does not cause dyspnea unless it leads to cardiac tamponade, which is a rare complication where fluid accumulates in the pericardial space
A nurse is preparing a client who has DVT for a venogram.
Which of the following actions should the nurse take?
Explanation
Assess for allergies to contrast material or iodine.This is because a venogram is a test that uses X-rays and a contrast dye to show blood flow in the veins.The contrast dye may contain iodine, which can cause an allergic reaction in some people.
Therefore, the nurse should check for any history of allergies to contrast material or iodine before the procedure.
Choice A is wrong because administering a sedative medication as prescribed is not necessary for a venogram.The procedure is minimally invasive and does not require sedation.
Choice C is wrong because applying a tourniquet to the affected limb is contraindicated for a venogram.A tourniquet would obstruct blood flow and interfere with the imaging of the veins.
Choice D is wrong because instructing the client to fast for 8 hours before the procedure is not required for a venogram.
The procedure does not affect the digestive system
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