Page 1 of 140
NSG 210 Clotting Exam ALL 500
Questions and Verified Solutions
Latest Update This Year
NSG 210 Clotting
QUESTION: The nurse is caring for a patient with type A hemophilia being admitted to the
hospital with severe pain and swelling in the right knee. The nurse should
a. Apply heat to the knee.
b. Immobilize the knee joint.
c. Assist the patient with light weight bearing.
d. Perform passive range of motion to the knee. - ANSWER-ANS: B. Immobilize the knee joint.
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to
decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated
initially, but after the bleeding stops, ROM and physical therapy are started.
1
, Page 2 of 140
QUESTION: Which assessment finding should the nurse caring for a patient with
thrombocytopenia communicate immediately to the health care provider?
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient's back. - ANSWER-ANS: B. The patient is difficult to
arouse.
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening
and requires immediate action. The other information should be documented and reported but
would not be unusual in a patient with thrombocytopenia.
QUESTION: The nurse is planning to administer a transfusion of packed red blood cells (PRBCs)
to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse
delegate to unlicensed assistive personnel (UAP)?
a. Verify the patient identification (ID) according to hospital policy.
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, Page 3 of 140
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion. - ANSWER-
ANS: B. Obtain the temperature, blood pressure, and pulse before the transfusion.
UAP education includes measurement of vital signs. UAP would report the vital signs to the
registered nurse (RN). The other actions require more education and a larger scope of practice
and should be done by licensed nursing staff members.
Q; A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a
deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when
the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH). - ANSWER-ANS: B. Discontinue the heparin
infusion.
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, Page 4 of 140
All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never
receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to
150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and
platelet transfusions increase the risk for thrombosis.
QUESTION: Which intervention will be included in the nursing care plan for a patient with
immune thrombocytopenic purpura (ITP)?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion. - ANSWER-ANS: B. Avoid
intramuscular (IM) injections.
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft
toothbrush can be used for oral care. There is no need to restrict activity or place the patient in
a private room.
4
NSG 210 Clotting Exam ALL 500
Questions and Verified Solutions
Latest Update This Year
NSG 210 Clotting
QUESTION: The nurse is caring for a patient with type A hemophilia being admitted to the
hospital with severe pain and swelling in the right knee. The nurse should
a. Apply heat to the knee.
b. Immobilize the knee joint.
c. Assist the patient with light weight bearing.
d. Perform passive range of motion to the knee. - ANSWER-ANS: B. Immobilize the knee joint.
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to
decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated
initially, but after the bleeding stops, ROM and physical therapy are started.
1
, Page 2 of 140
QUESTION: Which assessment finding should the nurse caring for a patient with
thrombocytopenia communicate immediately to the health care provider?
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient's back. - ANSWER-ANS: B. The patient is difficult to
arouse.
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening
and requires immediate action. The other information should be documented and reported but
would not be unusual in a patient with thrombocytopenia.
QUESTION: The nurse is planning to administer a transfusion of packed red blood cells (PRBCs)
to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse
delegate to unlicensed assistive personnel (UAP)?
a. Verify the patient identification (ID) according to hospital policy.
2
, Page 3 of 140
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion. - ANSWER-
ANS: B. Obtain the temperature, blood pressure, and pulse before the transfusion.
UAP education includes measurement of vital signs. UAP would report the vital signs to the
registered nurse (RN). The other actions require more education and a larger scope of practice
and should be done by licensed nursing staff members.
Q; A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a
deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when
the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH). - ANSWER-ANS: B. Discontinue the heparin
infusion.
3
, Page 4 of 140
All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never
receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to
150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and
platelet transfusions increase the risk for thrombosis.
QUESTION: Which intervention will be included in the nursing care plan for a patient with
immune thrombocytopenic purpura (ITP)?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion. - ANSWER-ANS: B. Avoid
intramuscular (IM) injections.
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft
toothbrush can be used for oral care. There is no need to restrict activity or place the patient in
a private room.
4
