Hesi Deep Vein Thrombosis With
Questions with correct answers 100%
1. Which term should the nurse use to most accurately report that Mrs. Adams may have developed a
clot in her vein that is causing her pain and the swelling in her leg? - Correct AnswersD.
Thrombophlebitis (refers to the inflammation of the vein that is often accompanied by a clot. Common
in lower extremities, can occur in superficial or deep veins of the legs. When deep veins are involved,
this is called deep vein thrombosis)
The nurse knows that there are 3 major factors involved in the development of DVT. There 3 factors are
referred to as Virchow's triad and include: Stasis of blood, vessel wall injury, and altered blood
coagulation. 2. Which of the medications taken by Mrs. Adams places her at increased risk for the
development of DVT? - Correct AnswersOral Contraceptives (known risk factor for thrombophlebitis)
3. Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT? -
Correct AnswersA. Measure calf circumference bilaterally
Venous Ultrasound or Doppler studies - Correct Answersnon invasic and provide evidence of a venous
obstruction by a thrombus.
Venography/ Venogram - Correct Answersinvolves the injection of a radio-contrast medium into the
venous system of the lower extemities. X-ray films taken will then allow visualization of any obstruction
in the venous circulation. Nursing Implications include assessment of allergies to iodine and adequate
renal function. Requires informed consent and pre-procedure hydration. Post-procedure nurse assesses
the insertion site, monitors vital signs, and provides adequate hydration.
4. Which route of administration should the nurse anticipate for this treatment? - Correct AnswersD.
Intravenous (acute thrombophlebitis controlled by heparin IV, frequently using a bolus dose, followed
by continuous IV infusion)
5. If pharamcologic therapy is initiated, which lab value would indicate to the nurse that heparinization
have been reached? - Correct AnswersB. APTT 65 seconds, control 35 seconds
APTT (Activated Partial Thromboplastin Time) - Correct AnswersRemember to reflect therepeutic
heparinization, the APTT should be 1.5-2 times greater than the control value in seconds.
, PT/INR Prothrombin Time/ International Normalized RatioRemember to reflect a therapeutic level of
warfarin (Coumadin) the PT should be 1.5-2 times the control value in seconds and INR should be 2-3. -
Correct Answers
6. What is the correct IV bolus dose of heparin? - Correct Answers6.80 ml
7. At what rate should the IV pump be set to deliver the prescribed rate of infusion? - Correct
Answers37
8. Which action should the nurse expect to initiate? - Correct AnswersC. Decrease the rate of infusion
9. When the oncoming nurse enters Mrs. Buckley's room, the IV pump is infusing at 50 ml/hr and Mrs.
Buckley has observable hematuria in her urinary catheter. Which action should the nurse initiate first? -
Correct AnswersB. Stop the heparin infusion
10. Which medication will be administered (heparin antagonist)? - Correct AnswersB. Protamine sulfate
11. Which description best identifies the purpose of an adverse occurence or incident report? - Correct
AnswersC. Hospital record that helps track patterns of risk to guide corrective action
12. What is the legal concern involved in this situation? - Correct AnswersD. Malpractice
13. Which nursing diagnosis should the nurse give the highest priority when planning care for Mrs.
Adams? - Correct AnswersB. Risk for injury (bleeding) related to anticoagulant therapy
14. Which nursing intervention should the nurse implement to help reduce the risk for abnormal
bleeding during heparin therapy. - Correct AnswersD. Maintain heparin on a continuous infusion pump
15. Which nursing interventions will reduce pain related to decreased venous flow? - Correct AnswersB.
Elevate the affected leg
E. Apply warm compress
Questions with correct answers 100%
1. Which term should the nurse use to most accurately report that Mrs. Adams may have developed a
clot in her vein that is causing her pain and the swelling in her leg? - Correct AnswersD.
Thrombophlebitis (refers to the inflammation of the vein that is often accompanied by a clot. Common
in lower extremities, can occur in superficial or deep veins of the legs. When deep veins are involved,
this is called deep vein thrombosis)
The nurse knows that there are 3 major factors involved in the development of DVT. There 3 factors are
referred to as Virchow's triad and include: Stasis of blood, vessel wall injury, and altered blood
coagulation. 2. Which of the medications taken by Mrs. Adams places her at increased risk for the
development of DVT? - Correct AnswersOral Contraceptives (known risk factor for thrombophlebitis)
3. Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT? -
Correct AnswersA. Measure calf circumference bilaterally
Venous Ultrasound or Doppler studies - Correct Answersnon invasic and provide evidence of a venous
obstruction by a thrombus.
Venography/ Venogram - Correct Answersinvolves the injection of a radio-contrast medium into the
venous system of the lower extemities. X-ray films taken will then allow visualization of any obstruction
in the venous circulation. Nursing Implications include assessment of allergies to iodine and adequate
renal function. Requires informed consent and pre-procedure hydration. Post-procedure nurse assesses
the insertion site, monitors vital signs, and provides adequate hydration.
4. Which route of administration should the nurse anticipate for this treatment? - Correct AnswersD.
Intravenous (acute thrombophlebitis controlled by heparin IV, frequently using a bolus dose, followed
by continuous IV infusion)
5. If pharamcologic therapy is initiated, which lab value would indicate to the nurse that heparinization
have been reached? - Correct AnswersB. APTT 65 seconds, control 35 seconds
APTT (Activated Partial Thromboplastin Time) - Correct AnswersRemember to reflect therepeutic
heparinization, the APTT should be 1.5-2 times greater than the control value in seconds.
, PT/INR Prothrombin Time/ International Normalized RatioRemember to reflect a therapeutic level of
warfarin (Coumadin) the PT should be 1.5-2 times the control value in seconds and INR should be 2-3. -
Correct Answers
6. What is the correct IV bolus dose of heparin? - Correct Answers6.80 ml
7. At what rate should the IV pump be set to deliver the prescribed rate of infusion? - Correct
Answers37
8. Which action should the nurse expect to initiate? - Correct AnswersC. Decrease the rate of infusion
9. When the oncoming nurse enters Mrs. Buckley's room, the IV pump is infusing at 50 ml/hr and Mrs.
Buckley has observable hematuria in her urinary catheter. Which action should the nurse initiate first? -
Correct AnswersB. Stop the heparin infusion
10. Which medication will be administered (heparin antagonist)? - Correct AnswersB. Protamine sulfate
11. Which description best identifies the purpose of an adverse occurence or incident report? - Correct
AnswersC. Hospital record that helps track patterns of risk to guide corrective action
12. What is the legal concern involved in this situation? - Correct AnswersD. Malpractice
13. Which nursing diagnosis should the nurse give the highest priority when planning care for Mrs.
Adams? - Correct AnswersB. Risk for injury (bleeding) related to anticoagulant therapy
14. Which nursing intervention should the nurse implement to help reduce the risk for abnormal
bleeding during heparin therapy. - Correct AnswersD. Maintain heparin on a continuous infusion pump
15. Which nursing interventions will reduce pain related to decreased venous flow? - Correct AnswersB.
Elevate the affected leg
E. Apply warm compress
