NRNP 6566 Week 5 Knowledge Check

1. Question: A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass inherabdomen.Shedevelopsacuteshortnessofbreathassociatedwithtachycardia 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 pulmonaryembolism? 2. Question: 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 andtheAPRNisremovingthe3-way Foleycatheterwhenthereisasuddenreleaseof 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. Resultswere: CBC with markedly decreased platelet count, peripheral blood smear showed decreasednumberofplateletsandpresenceoflargeplateletsandfragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level waslow. Based on the clinical presentation and laboratory data provided, what is your working diagnosis? 3. Question: 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? 4. Question: 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? 5. Question: 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? 6. Question: 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 be bridged once her warfarin is stopped for surgery. How would you manage this patient’s anticoagulants during the pre- and post-operative period? 7. Question: A 56-year-old male is taking warfarin 3 mg daily for treatment of a DVT / PE. He has his INR monitored every 4 weeks. His INR today is 3.1 and his last INR is 2.9. There have been no changes in his medications or health.What is his INR goal? How would you manage his INR today? 8. Question: A 66-year-old man is taking warfarin due to his atrial fibrillation. He noted that his gums were bleeding yesterday while eating. Today he had a coughing spell andhas been spitting up bright red blood ever since. The APRN is called by the ER with the result of the INR ordered. The INR is 9.8. What is the appropriate treatment of this patient? 9. Question: A 64-year-old man diagnosed with a pulmonary embolism is currently on warfarin. His INR readings have been very inconsistent, and the decision is made to change his medication to Rivaroxaban (Xarelto). What dose should be initiated and how would you discontinue thewarfarin? 10. Question: Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R foot and ankle were more swollen than they had been. She came to urgentcaretodaybecauseshewasafraidthattheinjurywasworsethanshethought itwas.T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some discomfort in the ankle and calf area. Pedal pulses equal bilaterally The APRN orders a duplex ultrasound of the right leg. Radiology reports that the ultrasound ispositive for a deep vein thrombosis. How would you manage this patient (include labs and meds)?