Practice Questions | 100% Pass Guarantee
Which statement below is incorrect about a deep vein thrombosis (DVT)?*
A. "Veins that are most susceptible to a deep vein thrombosis are the peroneal,
posterior tibial, popliteal and superficial femoral."
B. "DVTs tend to mostly occur in the lower extremities but can occur in the upper
extremities too."
C. "A deep vein thrombosis in the lower extremity has a low probability of becoming a
pulmonary embolism."
D. "A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts
in the vein." - correct answerc
- does not have a LOW probability it has a HIGH one
Select all the factors regarding a deep vein thrombosis that are included in Virchow's
Triad:
A. Hypocoagulability
B. Atherosclerosis
C. Endothelial damage
D. Stasis of venous blood
E. Excessive coagulability
F. Increased venous blood flow - correct answerc, d, e
- remember SHE: Stasis of Venous Blood, Hypercoagulability (means excessive
coagulability), Endothelial damage
Based on Virchow's Triad, select which patients below are at RISK for the development
of a deep vein thrombosis? Select all that apply:
A. A 55-year-old male with hyperlipidemia and diabetes.
B. A 70-year-old female with severe sepsis.
C. A 25-year-old male who uses intravenous drugs.
D. A 65-year-old female who is post-op day 1 after joint replacement surgery. - correct
answerb, c, d
You're developing a plan of care for a patient who is at risk for the development of a
deep vein thrombosis after surgery. What nursing intervention below would the nurse
NOT include in the patient's plan of care to prevent DVT formation?
A. The patient will eat all meals out of the bed daily by sitting in the bedside chair.
B. The nurse will apply sequential compression devices (SCDs) per physician's order to
the patient's lower extremities every night at bedtime.
C. The nurse will administer per physician's order Enoxaparin in the subcutaneous
tissue of the abdomen.
D. The patient will ambulate daily. - correct answerb
,- the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be
applied and worn by the patient anytime they are in bed or sitting. The only time a
patient should not wear the SCDs is when they're ambulating. Therefore, the nurse
would NOT just apply them at bedtime but during the day too.
The nurse is assessing a patient, who has many risk factors for the development of a
DVT, for signs and symptoms of a deep vein thrombosis. What signs and symptoms
below would possibly indicate a deep vein thrombosis is present?
A. Cool extremity
B. Decreases pulses
C. Redness
D. Pain
E. Warm extremity
F. Swelling
G. Cyanosis - correct answerc, d, e, f
True or False: Assessment of Homan's Sign is the most reliable indicator of a deep vein
thrombosis. - correct answerfalse
- Homan's Sign is NOT a reliable method for assessing for a DVT. It can lead to FALSE
positives.
A patient is receiving continuous IV Heparin for anticoagulation therapy for the
treatment of a DVT. In order for this medication to have a therapeutic effect on the
patient, the aPTT should be?
A. 0.5-2.5 times the normal value range
B. 2-3 times the normal value range
C. 1.5-2.5 times the normal value range
D. 1-3.5 times the normal value range - correct answerc
- An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a
therapeutic effect in a patient to prevent blood clots
if an aPTT is too low what can occur? - correct answerblood clots can form
if an aPTT is too high what can occur? - correct answerbleeding!
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an
aPTT of 110 seconds. What is your next nursing action per protocol?
A. Continue with the infusion because no change is needed based on this aPTT.
B. Increase the drip rate per protocol because the aPTT is too low.
C. Re-draw the aPTT STAT.
D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is
too high. - correct answerd
You're educating a patient about Warfarin (Coumadin) and how it is used to treat blood
clots. Which statements by the patient require you to re-educate them about how this
medication works? Select all that apply:
, A. "This medication will help dissolve the blood clot."
B. "This medication will prevent another blood clot from forming."
C. "This medication will help prevent the blood clot from becoming bigger in size."
D. "This medication starts working immediately after the first dose." - correct answera
and d
A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is
the therapeutic INR range for this medication?
A. 2-3
B. 1-3
C. 4-8
D. 0.5-2.5 - correct answera
Which option below is considered a positive Homan's Sign for the assessment of a deep
vein thrombosis (DVT)?
A. The patient reports pain when the foot is manually dorsiflexed.
B. The patient reports pain when the foot is manually plantarflexed.
C. The patient experiences pain when the leg is extended.
D. the patient experiences pain when the leg is flexed. - correct answera
- the MD must further investigate to see if there is a DVT present
Your patient has a deep vein thrombosis in the left lower extremity. The patient is
prescribed continuous IV Heparin. Select all the nursing interventions that are
appropriate for this patient:
A. Apply cool compresses to affected extremity
B. Measure leg circumference
C. Massage affected extremity
D. Elevate affected extremity above heart level
E. Encourage frequent ambulation
F. Monitor the patient's INR level
G. Monitor the patient's aPTT level
H. Apply sequential compression device (SCD) to the affected extremity - correct
answerb, d, g
- a warm compress should be used
- NEVER massage the site because it could dislodge the clot and make it move
somewhere else
- patient needs bed rest
- the SCD are not used because they can also dislodge the clot
A patient's D-dimer result is <500 ng/mL. The nurse knows that the D-dimer assesses
_______ and this result means?
A. fibrin degradation fragment; positive for a blood clot
B. platelet degradation protein; negative for a blood clot
C. clotting factors; positive for a blood clot
D. fibrin degradation fragment; negative for a blood clot - correct answerd