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Chapter 26: Drugs Used to Treat Thromboembolic Disorders
MULTIPLE CHOICE
1. A trauma patient arrives in the emergency department via EMS. He is bleeding
profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will
most likely administer which medication that counteracts the action of heparin? a.
Warfarin sodium (Coumadin)
b. Enoxaparin (Lovenox)
c. Protamine sulfate
d. Vitamin K
ANS: C
Protamine sulfate is the antidote to heparin. With the patient’s risk of fluid volume deficit
as a result of trauma, the primary intervention would be to counteract the effects of heparin
to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract
hemorrhage. Lovenox is chemically related to heparin and would not counteract
hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin
(Coumadin), not heparin.
DIF: Cognitive Level: Comprehension REF: Page 414 OBJ: 3 | 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Perfusion; Safety
2. A patient receiving IV heparin therapy for a deep vein thrombosis (DVT) in his right
calf asks why his calf remains painful, edematous, and warm to touch after 2 days of
anticoagulant therapy. Which response by the nurse is most accurate?
a. “It takes at least 3 days for the symptoms to resolve once the clot dissolves.”
b. “Heparin does not dissolve blood clots but neutralizes clotting factors, preventing
extension of the clot and the possibility of it traveling elsewhere in your body.”
c. “I will report this to your health care provider because there may be a need to look at
alternative treatments.”
d. “You appear anxious. The health care provider will eventually put you on ticlopidine,
which allows for an earlier discharge.”
ANS: B
Heparin is used to treat a thromboembolism and promote neutralization of activated
clotting factors, preventing the extension of thrombi and the formation of emboli. Heparin
will minimize tissue damage by preventing it from developing into an insoluble, stable
thrombus. It is inappropriate to tell a patient how long it will take to dissolve a clot. The
patient’s question does not warrant notification of the health care provider. Telling the
patient that the health care provider will be starting the patient on ticlopidine is
inappropriate and inaccurate.
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DIF: Cognitive Level: Analysis REF: Pages 412-413
OBJ: 3 TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Communication; Patient Education; Perfusion; Clotting
3. A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30
seconds. Which nursing intervention is most accurate?
a. Document in the nursing notes that these results are within therapeutic range.
b. Note the RBC count and wait for the health care provider to make the next round to
discuss all laboratory values.
c. Stop the heparin drip.
d. Assess the patient for signs and symptoms of decreased sensorium.
ANS: C
Heparin dosage is considered to be in the normal therapeutic range if the aPTT is 1.5 to 2.5
times the control value. The patient’s aPTT value is above the therapeutic range, which
puts her at risk for hemorrhage. The most appropriate nursing action would be to stop the
heparin drip. These results cannot be documented as being within the normal therapeutic
range. RBC count and mental status are not relevant in assessing therapeutic response to
anticoagulation.
DIF: Cognitive Level: Application REF: Page 414 OBJ: 4 | 5
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
4. Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-
molecular-weight heparin product?
a. Expel the air bubble from the prefilled syringe.
b. Leave the needle in place for 10 seconds after injection.
c. Administer the medication into the deltoid muscle.
d. Massage the site after injection to increase absorption.
ANS: B
The needle is left in place for 10 seconds after injection. Air is not expelled from the
prefilled syringe. This medication is not administered intramuscularly. The site should not
be massaged to increase absorption.
DIF: Cognitive Level: Application REF: Page 409 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Clinical Judgment; Safety
5. A patient is receiving 1400 units of heparin/hour on an IV pump. The aPTT time is 54.
The laboratory control is 25. Which action by the nurse is accurate? a.
Bolus the patient with an additional 5000 units of heparin.
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Chapter 26: Drugs Used to Treat Thromboembolic Disorders
MULTIPLE CHOICE
1. A trauma patient arrives in the emergency department via EMS. He is bleeding
profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will
most likely administer which medication that counteracts the action of heparin? a.
Warfarin sodium (Coumadin)
b. Enoxaparin (Lovenox)
c. Protamine sulfate
d. Vitamin K
ANS: C
Protamine sulfate is the antidote to heparin. With the patient’s risk of fluid volume deficit
as a result of trauma, the primary intervention would be to counteract the effects of heparin
to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract
hemorrhage. Lovenox is chemically related to heparin and would not counteract
hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin
(Coumadin), not heparin.
DIF: Cognitive Level: Comprehension REF: Page 414 OBJ: 3 | 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Perfusion; Safety
2. A patient receiving IV heparin therapy for a deep vein thrombosis (DVT) in his right
calf asks why his calf remains painful, edematous, and warm to touch after 2 days of
anticoagulant therapy. Which response by the nurse is most accurate?
a. “It takes at least 3 days for the symptoms to resolve once the clot dissolves.”
b. “Heparin does not dissolve blood clots but neutralizes clotting factors, preventing
extension of the clot and the possibility of it traveling elsewhere in your body.”
c. “I will report this to your health care provider because there may be a need to look at
alternative treatments.”
d. “You appear anxious. The health care provider will eventually put you on ticlopidine,
which allows for an earlier discharge.”
ANS: B
Heparin is used to treat a thromboembolism and promote neutralization of activated
clotting factors, preventing the extension of thrombi and the formation of emboli. Heparin
will minimize tissue damage by preventing it from developing into an insoluble, stable
thrombus. It is inappropriate to tell a patient how long it will take to dissolve a clot. The
patient’s question does not warrant notification of the health care provider. Telling the
patient that the health care provider will be starting the patient on ticlopidine is
inappropriate and inaccurate.
This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:43:12 GMT -05:00
https://www.coursehero.com/file/25984117/26-1pdf/
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DIF: Cognitive Level: Analysis REF: Pages 412-413
OBJ: 3 TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Communication; Patient Education; Perfusion; Clotting
3. A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30
seconds. Which nursing intervention is most accurate?
a. Document in the nursing notes that these results are within therapeutic range.
b. Note the RBC count and wait for the health care provider to make the next round to
discuss all laboratory values.
c. Stop the heparin drip.
d. Assess the patient for signs and symptoms of decreased sensorium.
ANS: C
Heparin dosage is considered to be in the normal therapeutic range if the aPTT is 1.5 to 2.5
times the control value. The patient’s aPTT value is above the therapeutic range, which
puts her at risk for hemorrhage. The most appropriate nursing action would be to stop the
heparin drip. These results cannot be documented as being within the normal therapeutic
range. RBC count and mental status are not relevant in assessing therapeutic response to
anticoagulation.
DIF: Cognitive Level: Application REF: Page 414 OBJ: 4 | 5
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
4. Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-
molecular-weight heparin product?
a. Expel the air bubble from the prefilled syringe.
b. Leave the needle in place for 10 seconds after injection.
c. Administer the medication into the deltoid muscle.
d. Massage the site after injection to increase absorption.
ANS: B
The needle is left in place for 10 seconds after injection. Air is not expelled from the
prefilled syringe. This medication is not administered intramuscularly. The site should not
be massaged to increase absorption.
DIF: Cognitive Level: Application REF: Page 409 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Clinical Judgment; Safety
5. A patient is receiving 1400 units of heparin/hour on an IV pump. The aPTT time is 54.
The laboratory control is 25. Which action by the nurse is accurate? a.
Bolus the patient with an additional 5000 units of heparin.
This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:43:12 GMT -05:00
https://www.coursehero.com/file/25984117/26-1pdf/
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