NRNP 6566 Week 5 Knowledge Check

NRNP 6566 Week 5 Knowledge Check QUESTION 1 1.A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass in her abdomen. She develops acute shortness of breath associated with tachycardia and hypotension. CT Scan of the chest is positive for multiple small pulmonary embolism. What medication and dosing would you order initially to treat the pulmonary embolism? This patient should be given fondaparinuc (Arixtra) subcutaneously. Dosing is weight- based: 1.5 mg SQ once daily (for weight less than 50 kg 2.7.5 mg SQ once daily (for weight ranges from 50-100 kg) 3.10 mg SQ once daily (for weight exceeding 100 kg). QUESTION 2 1. A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were: CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. Based on the clinical presentation and laboratory data provided, what is your working diagnosis? The working diagnosis for this patient is disseminated intravascular coagulation (DIC). It is an acquired coagulation disorder that is most commonly caused by infections (gram negative sepsis), malignant neoplasm, obstetric complication, liver disease, trauma, and burns. This patient is positive for urinary tract infection. Thrombocytopenia (decreased platelets), prolonged PT and aPTT, low fibrinogen levels, positive D-dimer, and schistocytes are all indicative of an acute uncompensated DIC (active hemorrhagic event). QUESTION 3 1. A 26-year-old male was injured in a motorcycle crash 3 days ago. He sustained an acute subdural hematoma, acetabular fracture, and L2 fracture with spinal cord injury and resulting paralysis. He has a warm swollen right lower leg. Duplex ultrasound of the right lower leg is positive. What is the best treatment for this patient? The duplex ultrasound of the right lower leg is positive indicating DVT. Patient is also at higher risk for pulmonary embolism with the paralysis and the acetabular fracture. Anticoagulation would have been indicated for this patient, but the subdural hematoma would be a contraindication for anticoagulation. According to the ACCP guidelines, patients with acute proximal DVT of the leg and contraindication to anticoagulation, the use of an IVC filter is recommended. QUESTION 4 1. A 44-year-old male is admitted to the orthopedic unit following a motor vehicle crash. He has a femur fracture of the right leg. He is not actively bleeding and healthy. He weighs 185 pounds. What should the APRN order as DVT prophylaxis? This patient is at an increased risk of thrombosis and has no active bleeding or low risk for bleeding, so the ACCP recommends anticoagulant thromboprophylaxis with LMWH (low molecular weight heparin), low dose unfractionated heparin (LDUH) BID, LDUH TID or fondaparinux (Grade1B). QUESTION 5 1. A 16-year-old male is brought to the Urgent Care by her mother who states that the girl has had an abnormal number of bruises and “funny looking red splotches” on her legs. Bruises were noted about 2 weeks ago and have increased in number since this time. There is no history of trauma to explain the bruising. Past medical history not remarkable and she takes no medications. The mother does state the girl is recovering from a “bad case of mono” and was on bedrest at home for the past 3 weeks. The girl noticed that her gums were slightly bleeding when she brushed her teeth that morning. Lab work completed show a normal hemoglobin and hematocrit with normal white blood cell (WBC) count and differential. Platelet count of 50,000/mm3 was the only abnormal finding. The staff also noticed that the venipuncture site oozed for a few minutes after pressure was released. Immune thrombocytopenia purpura (ITP) is suspected. What additional diagnostics should be ordered? If this diagnosis is confirmed, how would you treat it? Thrombocytopenia is the hallmark of Immune or idiopathic thrombocytopenia purpura (ITP) which was found in this patient’s lab work. There is no definitive test for ITP and the diagnosis is typically by exclusion. Antinuclear antibody testing may be done to assess for autoimmune process ( risk factor). Bone marrow biopsy can be done to rule out myelodysplasia. Treatment is not usually initiated unless platelet count is less than 20,000or patient is symptomatic. Once confirmed, initial treatment includes prednisone, 1-2 mg/kg/day. A high dose of intravenous gamma globulin (1 gm/kg for 1-2 days) is also effective. When prednisone therapy fails, splenectomy may be indicated. QUESTION 6 1. A 44-year-old female with a mechanical mitral heart valve is scheduled for elective abdominal surgery next week. The patient currently takes warfarin 5 mg daily for prevention of thrombus. The patient is high risk for blood clot formation and needs to