The Client with Thrombophlebitis and Embolus Formation
64. A client is discharged after being hospitalized for thrombophlebitis.
She will be driving home with her daughter, who lives 2 hours away.
During the 2-hour ride the client should
1. perform arm circles while riding in the car.
2. perform active ankle and foot range-of-motion exercises.
will promote muscular contraction and provide support to the venous system.
It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position.
3. elevate her legs while riding in the car.
4. take an ambulance home.
65. A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made.
One common cause of pulmonary embolism is
hardening of the arteries
2. aneurysm formation.
the abnormal dilation of a vessel
3. deep vein thrombosis (DVT).
venous stasis in the legs when there is a lack of the skeletal muscle pump
that enhances venous return to the heart.
When a client is confined to bed rest, venous compression occurs
because of the position of the lower extremities.
This increased pressure causes damage to the intima lining of the veins
and causes platelets to adhere to the damaged site.
DVT increases the risk
that a displaced plaque will become a pulmonary embolus.
4. varicose veins.
swollen, tortuous veins.
66. A client receives a thromboiytic agent.
The expected outcome of this drug therapy includes
1. improved cerebral perfusion.
2. decreased vascular permeability.
3. dissolved emboli.
Thrombolytic agents are used for clients with a history of thrombus formation, cerebral vascular accidents, and chronic atrial fibrillation.
4. prevention of further cerebral hemorrhage.
67. A client who weighs 187 pounds has an order to receive enoxaparin (Loven ox) 1 mg/kg. This drug is available in a concentration of 30 mg/O.3 mL.
What dose would the nurse administer in milliliters'?
First convert pounds to killograms (kg) by using the formula,
1 kg= 2.2 pounds, 187 / 2.2 = 85 kg.
The physician's order is for the client to receive enaxaparin (Lovenox) 1 mg/kg. Therefore, the client is to receive 85 mg.
The desired dose in milliliters then can be calculated by using the formula of desired dose (0) divided by dose or strength of dose on hand (H) times volume (V).
185 (mg) x 0.3 ml = 25.5 mg/mL.
25.5 mg 7 30 = 0.85mL.
68. The nurse understands that a client on complete bed rest is at risk of developing which of the following complications involving the venous system?
1. Air embolus.
a result of air entering the vascular system.
2. Fat embolus.
the presence of intracellular fat globules in the lung parenchyma
and peripheral circulation after long bone fractures.
3. Stress fractures.
the musculoskeletal system.
an inflammation of a vein.
etiology involves stasis of blood, increased blood coagulability,
and vessel wall injury.
The symptoms are pain, swelling, and deep muscle tenderness.
69. The client has an intravenous (IV) catheter in the left antecubital space.
The nurse notes that the area is swollen and red, and the client complains of discomfort at the site. The nurse realizes that 65% of the clients receiving IV therapy will develop
2. deep vein thrombophlebitis.
3. superficial vein thrombus.
4. superficial vein thrombophlebitis.
70. A client is receiving an IV infusion of 5% dextrose in water (D5W).
The skin around the IV insertion site is red, warm to touch, and painful.
The nurse should first
1. administer acetaminophen (Tylenol).
only if ordered by the physician.
2. change the D5 W to normal saline.
The type of infusion cannot be changed without a physician's order,
and such a change would not help in this case.
3. discontinue the IV.
The nurse should restart the IV elsewhere
and then apply a warm compress to the affected area.
4. place a warm compress on the area.
71. Bed rest is related to an increased incidence of thrombophlebitis.
The plan of care for a client on bed rest would not include
1. Turning every 2 hours.
2. Passive and active range-of-motion exercises.
3. Use of thromboembolytic disease support (TED) hose.
help prevent venous stasis in the lower extremities.
4. Maintaining the client in the supine position.
Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities.
Keeping the client in the supine position would not be appropriate.
Three factors contribute to the formation of venous thrombus and thrombophebitis: damage to the inner lining of the vein (prolonged pressure),
hypercoagulability of the blood, and venous stasis.
72. The client is admitted with left lower leg pain, a positive Homans sign,
and temperature greater than 100.4°F (380C). The nurse suspects
1. an aortic aneurysm.
2. DVT in the left leg.
3. IV drug abuse.
4. intermittent claudication.
73. The nurse understands that certain risk factors are related to DVT.
Which of the following is one such risk factor?
1. The client exercises on a regular basis.
helps prevent venous stasis and DVT
2. The client lives alone at home.
Living alone has no link to development of DVT.
3. The client recently had abdominal surgery.
developing a DVT, thrombophlebitis, or thromboembolism
4. The client wears anti-thrombotic hose on a regular basis
a measure to help prevent venous stasis.
74. A client is admitted to the unit with a diagnosis of thrombophlebitis and DVT of the right leg. A loading dose of heparin has been given in the emergency room, and IV heparin will be continued for the next several days. Care of this client will involve
1. administering aspirin as ordered.
Taking aspirin when the client is on heparin is contraindicated.
2. encouraging green leafy vegetables in the diet.
Green leafy vegetables are high in vitamin K
therefore are not recommended for clients receiving heparin.
3. monitoring the client's prothrombin time (PT).
Monitoring of the client's PT is done
when the client is receiving warfarin sodium (Coumadin).
4. monitoring the client's activated partial thromboplastin time (aPTT) and international normalized ratio (INR).
Heparin dosage is usually determined by the doctor
based on the client's aPTT and INR laboratory values.
Therefore, the nurse monitors these values to prevent complications.
75. With a client who has undergone abdominal or pelvic surgery,
the nurse implements strategies to prevent a DVT.
Interventions for promoting the circulation in the lower extremities include
2. encouraging deep breathing.
postoperatively, but it does not prevent DVT.
4. using pneumatic compression stockings.
an intervention used to prevent DVT.
1. avoiding fluids.
3. remaining sedentary.
early ambulation, leg exercises if the client is confined to bed,
adequate fluid intake, and administering anticoagulant medication as ordered.
76. A client with DVT has an edematous right lower extremity.
The client lies on her right side frequently.
Rubor is noted on the lateral aspect of the right ankle.
From the data collected, the appropriate nursing diagnosis for this client would be
1. Activity Intolerance related to complaints of pain in lower right extremity.
2. Altered Health Maintenance related to lack of knowledge about DVT.
3. Pain related to edema.
4. Risk for Impaired Skin Integrity.
the primary nursing diagnosis.
With rubor or hyperemia, there is increased blood flow to the area, raising filtration pressure. As a result, capillary permeability is altered, causing damage to capillary walls. The increased permeability, obstruction of lymphatic drainage, elevation of venous pressure, and decrease in plasma protein osmotic force results in edema.
77. The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week.
The client is obese and uses estrogen-based oral contraceptives.
This client is at high risk for development of
3. Raynaud's disease.
The data suggest an increased risk for thrombophlebitis.
The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives.
78. The nurse observes that an older woman has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs.
These are commonly called
is a localized, abnormal dilatation of a blood vessel.
is a fatty tumor.
an open sore or lesion of the skin or mucous membrane,
accompanied by sloughing of inflamed necrotic tissue
tortuous, distended veins where blood has pooled.
commonly observed in the lower extremities.
79. Which of the following clients is at risk for varicose veins?
1. A client who has had a cerebral vascular accident.
2. A client who has had anemia.
3. A client who has had thrombophlebitis.
Secondary varicosities can result from previous thrombophlebitis
of the deep femoral veins, with subsequent valvular incompetence.
4. A client who has had transient ischemia attacks.
80. A client weighs 300 pounds and has a history of DVT and thrombophlebitis.
When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will
1. avoid exercise.
In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program.
2. lose weight.
Maintaining ideal body weight is the goal.
3. perform leg lifts every 4 hours.
Performing leg lifts provides muscular activity
should be done more often than every 4 hours.
Depending on the individual,
leg lifts mayor may not be an appropriate form of activity.
4. wear support hose using rubber bands to hold the stockings up.
However, the client should not use rubber bands to hold the stockings up.
81. Which instructions would the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having DVT? Select all that apply.
1. Checking urine for bright blood and a dark smoky color.
Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT.
Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant over dosage.
Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color.
2. Daily walking as a good exercise.
Daily ambulation is an excellent activity
to keep the venous blood circulating
and thus to prevent blood clots from forming in the lower extremities.
3. Using garlic and ginger which may decrease bleeding time.
The herbs garlic and ginger increase the bleeding time
should not be used when a client is on anticoagulant therapy.
4. Performing foot/leg exercises and walking around the airplane cabin on long flights.
Clients who have had previous DVT's should avoid activities
that cause stagnation and pooling of venous blood.
Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return.
5. Prevention as the best treatment for DVT.
Instructing the client is important because clients with DVT are at high risk for pulmonary emboli (PE), which can be fatal.
The client can be taught risk factors for DVT and PE.
In addition, recommendations also are standard protocol in practice
and should be shared with the client for home care purposes.
6. Avoiding surface bumps because the skin is prone to injury.
Older adults should be monitored closer for bleeding because the skin becomes thinner and the capillaries become more fragile with the aging process.
82. When an arterial embolus has been diagnosed an emergency embolectomy
may be considered if the involved extremity is viable.
After an embolectomy, a priority goal is to
1. administer pain medication.
2. administer the anticoagulants as ordered.
3. encourage activity within the guidelines specified by the physician.
4. monitor the pulses.
Monitoring peripheral pulses below the site of occlusion
checks the arterial circulation in the involved extremity.
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