NR304 Exam 1
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5
days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why
both anticoagulants are necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic
level."
B. "I will call the provider to get a prescription for discontinuing the IV heparin today."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." -
ANSWER: A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a
therapeutic level."
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE).
The nurse should instruct the client to avoid which of the following unsafe actions?
A. Elevating the feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery - ANSWER: B. Massaging her legs
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the
following surgical procedures places the client at risk for deep-vein thrombosis?
A. Myringotomy
B. Laparoscopic appendectomy
C. Hip arthroplasty
D. Cataract extraction - ANSWER: C. Hip arthroplasty
A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse
anticipates which of the following orders when notifying the provider of this finding?
A. Obtain a venous duplex ultrasound
B. Obtain impedance plethysmography
C. Monitor Homan's sign
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5
days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why
both anticoagulants are necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic
level."
B. "I will call the provider to get a prescription for discontinuing the IV heparin today."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." -
ANSWER: A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a
therapeutic level."
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE).
The nurse should instruct the client to avoid which of the following unsafe actions?
A. Elevating the feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery - ANSWER: B. Massaging her legs
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the
following surgical procedures places the client at risk for deep-vein thrombosis?
A. Myringotomy
B. Laparoscopic appendectomy
C. Hip arthroplasty
D. Cataract extraction - ANSWER: C. Hip arthroplasty
A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse
anticipates which of the following orders when notifying the provider of this finding?
A. Obtain a venous duplex ultrasound
B. Obtain impedance plethysmography
C. Monitor Homan's sign