Enhances the activity of antithrombin III, which will inhibit thrombin and the conversion of fibrinogen to fibrin. B. Join the nursing revolution. (ex: up to 4.5). This causes WBCs, RBCs, and platelets to stick together within the vein. The therapeutic INR range is 2-3. (2019). A client with deep vein thrombosis (DVT) has an order for enoxaparin (Lovenox). Therefore, the blood has to flow back to the heart via the veins, and it does this with the assistance of healthy vein valves and the muscles within the extremity. Deep vein thrombosis is a condition in which - 1/12. How does a clot form and what substances are involved? You can view your scores and the answers to all the questions by clicking on the SHOW RESULT red button at the end of the question. D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high. Test. So this means a clot has formed and has started to break down. Make sure the patient is wearing them while sitting or in bed. We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. 4. Sequential Easy First Hard First. Used in combination with Warfarin until INR is therapeutic and then Heparin is discontinued. Enter your email address below and hit "Submit" to receive free email updates and nursing tips. Mometrix Academy is a completely free resource provided by Mometrix Test Preparation. A deep vein thrombosis is a type of venous thromboembolism (VTE). Remember “SHE”: Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Text Mode – Text version of the exam 1. Copyright © 2021 RegisteredNurseRN.com. Difficulty. All Rights Reserved. Once a DVT has developed it could result in a pulmonary embolism (PE). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Deep Vein Thrombosis (DVT) NCLEX Review. Pulmonary embolism due to deep vein thrombosis (DVT). A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. Example: Liver disease, MI, surgery (heart), cancer, pregnancy. The risk factors associated with deep vein thrombosis are oral contraceptive use, obesity, hormone replacement therapy, hypercoagulable states, old age, type A blood, multiparity, not nulliparity, and among clients who have had major surgery and/or prolonged immobility. What signs and symptoms below would possibly indicate a deep vein thrombosis is present? Based on Virchow’s Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Diagnosis and Treatment of Venous Thromboembolism | CDC. Join the nursing revolution. 13. Nursing Study Guide for Deep Vein Thrombosis. A. A. fibrin degradation fragment; positive for a blood clot, B. platelet degradation protein; negative for a blood clot, C. clotting factors; positive for a blood clot, D. fibrin degradation fragment; negative for a blood clot. What are some conditions that cause damage the endothelial lining? Play as. Write. The nurse will apply sequential compression devices (SCDs) per physician’s order to the patient’s lower extremities every night at bedtime. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Option C is wrong because it should say:  “A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.”. Compression stockings per MD order: provides a specific amount of compression to help decrease risk of blood clot development. NCLEX Review Questions Chapter 37 From Evolve Resources III. The answer is B. Extend the patient’s leg and manually dorsiflex the patient’s foot (bend it up towards the shin). Remember “SHE”: Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. A 70-year-old female with severe sepsis. The nurse is preparing to educate the client on the new prescription for an anti-thrombotic medication. Virchow’s Triad gives us three main factors that can lead to blood clot formation within a vein. “Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral.”, B. NCLEX-PN Practice Test Questions. The main reason for this is due to a disease process, but it can be due to other reasons. The patient reports pain when the foot is manually plantarflexed. To improve patient outcomes nurses should focus on preventing DVT. mt6399. D. the patient experiences pain when the leg is flexed. As the nurse, you will want to be familiar with the prevention of a blood clot (venous thromboembolism VTE), management of a DVT, and anticoagulation therapy. NOTE: This list is not a complete list. B. Now test your knowledge by taking the Deep Vein Thrombosis NCLEX Questions quiz. Take them off when the patient is walking. This quiz is copyright RegisteredNurseRn.com. Select all the nursing interventions that are appropriate for this patient: A. A deep vein thrombosis (DVT) is a blood clot that forms within the vein. The other type of VTE is a pulmonary embolism, which is where a deep vein thrombosis breaks off within the vein and goes to the lungs. (acts fast) given IV or subq…weight-based, Monitor aPTT (activated partial thromboplastin time): 1.5 to 2.5 times normal ranges, >80 seconds risk for bleeding….dose decreased, <60 seconds NOT therapeutic…risk for clots and may need dosage increased. Deep Vein Thrombosis (DVT) NCLEX Review. C. The patient experiences pain when the leg is extended. The answer is D. The aPTT is 110 seconds, which is too high. Retrieved 1 November 2019, from https://www.cdc.gov/ncbddd/dvt/facts.html. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. 10. All the other statements are true about a DVT. The site provides NCLEX-RN and NCLEX-PN questions that are based on the materials developed by 2020 National Council of State Boards of Nursing and are similar to those you’ll find on the official exam. The answer is C. An  aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. Fibrin causes the big problem in terms of a clot developing because fibrin is like strands of mesh. Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. They’re NOT to be applied to the extremity that has an active DVT (can lead to dislodgement). 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So we’ve seen how a clot forms now let’s talk about what you can see in your patient that may have a DVT. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. Anyone can develop a deep vein thrombosis, especially if these risk factors are present. It done by manually (forced) dorsiflexing the patient’s foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan’s Sign. 9. Try this amazing Quiz: NCLEX Nursing Questions On Cardiovascular System quiz which has been attempted 3674 times by avid quiz takers. The other type of VTE is a pulmonary embolism, which is where a deep vein thrombosis breaks off within the vein and goes to the lungs. PLAY. Last Updated/Verified: Aug 25, 2020. Do you think you could pass the NCLEX? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest…ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot…they are used to PREVENT blood clots. NCLEX Review: DVT – Prevention and Treatment. Which option below is considered a positive Homan’s Sign for the assessment of a deep vein thrombosis (DVT)? During the Quiz End of Quiz. Created by. This test is designed to help you prepare for either the NCLEX-RN exam or the NCLEX-PN exam. The answers are B, D, G. Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Nursing Prioritization, Delegation and Assignment #2 | 15 Questions; The answers are B, C, and D. Virchow’s Triad details the THREE factors for blood clot formation within the vessel. Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting. Prophylactic medications: after surgery (post-op), especially joint replacement surgery like the hip… Example: Enoxaparin (subq injection), Don’t rub or massage affected extremity (can dislodge clot), Elevate the affected extremity above heart level (promotes blood return and decreases swelling), Compresses (warm/moist) helps pain and circulation. Continue with the infusion because no change is needed based on this aPTT. 12. C. A 25-year-old male who uses intravenous drugs. Questions to ask if you suspect DVT • If the patient complains of lower leg or calf pain, do a further assessment of the extremity. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein in the leg or arm. B. 1. So, when they start to work within the vessel it recruits other chemicals called clotting factors. It takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level. A deep vein thrombosis (DVT) is a blood clot that forms within the vein. Patient needs to be ambulating daily and out of the bed with all meals, if possible. 1. The platelets start to collect at the edges of the vessel, usually within the cusps of the vein’s valve. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin. If the vein’s valves are damaged or the muscles aren’t working (or being used) blood isn’t going to flow back very well and a blood clot can develop. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. Endothelial damage to the vein: This endothelial is a layer of cells that lines the inside of the vein. The answer is D. A d-dimer test assess fibrin degradation fragment. Since it’s a Vitamin K antagonist, it will work to inhibit clotting factors from using Vitamin K. Slow onset….takes 3-5 day for patient to become therapeutic, Monitor PT/INR…therapeutic INR is 2-3 (less than 2…not therapeutic) and greater than 3 at risk for bleeding). These devices can come unplugged from wall and quit working. The nurse knows that the D-dimer assesses _______ and this result means? This is a protein fragment that hangs out in the blood when a clot breaks down. Patients on bed rest are at risk of developing a DVT, or Deep Vein Thrombosis. Teach patient to perform exercises by flexing and extending feet and legs every hour while awake. Deep vein thrombosis can cause leg pain or swelling, but also can occur with no symptoms.Deep vein thrombosis can develop if you have certain medical conditions that affect how your blood clots. This test doesn’t tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn’t necessarily mean the patient has a clot because some disease processes can cause a false positive. The Nurse Plus Academy is designed to help you pass your NCLEX Exam. What nursing intervention below would the nurse NOT include in the patient’s plan of care to prevent DVT formation? If you find benefit from our efforts here, check out our premium quality NCLEX study guide to take your studying to the next level. These devices wrap around the legs and inflate and deflate to help move blood flow (similar to walking). It is very common that a patient will be on Heparin while taking Warfarin until INR levels are therapeutic. What veins are most susceptible for a DVT? If misdiagnosed, unrecognized, or untreated, PE can cause death quickly—within just an hour. Prevention…very simple but so beneficial…nurses play a HUGE role with this! Why are the other options wrong? You’re educating a patient about Warfarin (Coumadin) and how it is used to treat blood clots. Deep Vein Thrombosis (DVT) NCLEX review for nursing students!. Patients who’ve had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc. sudden shortness of breath, decreased oxygen saturation, fast heart rate, chest pain, very anxious, sweating, coughing, Fitted and applied properly as prescribed. A nurse is advising a patient with Chronic Fatigue Syndrome on infection control procedures. B. Blood cannot just hang out and become static within a vessel. Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. 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