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Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/EChapter 30

Question 1Type: MCSAThe nurse is managing care for a patient with cirrhosis of the liver. The nurse teaches the patient about how to avoid injury that may result in bleeding. The patient asks the nurse why he is at risk to start bleeding. What is the best response by the nurse?

1. "Because your liver is injured and unable to manufacture platelets."2. "Because your liver thickens your blood so it is less likely to clot."3. "Because your liver is injured and cannot make clotting factors."4. "Because your liver is breaking down your clotting factors too quickly."Correct Answer: 3Rationale 1: The liver is responsible for the production of essential clotting factors necessary to prevent bleeding. The liver is not responsible for breaking down clotting factors. The liver is not responsible for making the blood thick. The liver is not responsible for manufacturing platelets.Rationale 2: The liver is responsible for the production of essential clotting factors necessary to prevent bleeding. The liver is not responsible for breaking down clotting factors. The liver is not responsible for making the blood thick. The liver is not responsible for manufacturing platelets.Rationale 3: The liver is responsible for the production of essential clotting factors necessary to prevent bleeding. The liver is not responsible for breaking down clotting factors. The liver is not responsible for making the blood thick. The liver is not responsible for manufacturing platelets.Rationale 4: The liver is responsible for the production of essential clotting factors necessary to prevent bleeding. The liver is not responsible for breaking down clotting factors. The liver is not responsible for making the blood thick. The liver is not responsible for manufacturing platelets.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-2Question 2Type: MCSAThe nurse is managing care for a patient with a DVT (deep vein thrombosis) of the right calf. The patient receives heparin intravenously (IV). What is the priority outcome for this patient?

1. The patient will comply with dietary restrictions.2. The patient will keep the right leg elevated on two pillows.3. The patient will not disturb the intravenous infusion.4. The patient will not experience bleeding.Correct Answer: 4Rationale 1: An absence of bleeding is a priority outcome for any patient receiving anticoagulant therapy. Disturbing the intravenous (IV) could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high of a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high of a priority as an absence of bleeding.Rationale 2: An absence of bleeding is a priority outcome for any patient receiving anticoagulant therapy. Disturbing the intravenous (IV) could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high of a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high of a priority as an absence of bleeding.Rationale 3: An absence of bleeding is a priority outcome for any patient receiving anticoagulant therapy. Disturbing the intravenous (IV) could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high of a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high of a priority as an absence of bleeding.Rationale 4: An absence of bleeding is a priority outcome for any patient receiving anticoagulant therapy. Disturbing the intravenous (IV) could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high of a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high of a priority as an absence of bleeding.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-5Question 3Type: MCSAThe patient receives warfarin (Coumadin). The nurse notes that the patient's morning international normalized ratio (INR) is 7-. What are the priority nursing interventions at this time?

1. Hold the next dose of warfarin (Coumadin) and repeat the international normalized ratio (INR).2. Administer protamine sulfate and hold the next dose of warfarin (Coumadin).3. Hold the next dose of warfarin (Coumadin) and contact the physician.4. Administer vitamin K and hold the next dose of warfarin (Coumadin).Correct Answer: 4Rationale 1: Vitamin K is the antidote for warfarin (Coumadin) overdose and its administration is warranted with an international normalized ratio (INR) of 7-. Repeating the international normalized ratio (INR) is appropriate, but the patient must receive vitamin K immediately. Protamine sulfate is the antidote for heparin, not warfarin. Consulting the physician is appropriate, but the patient must receive vitamin K immediately.Rationale 2: Vitamin K is the antidote for warfarin (Coumadin) overdose and its administration is warranted with an international normalized ratio (INR) of 7-. Repeating the international normalized ratio (INR) is appropriate, but the patient must receive vitamin K immediately. Protamine sulfate is the antidote for heparin, not warfarin. Consulting the physician is appropriate, but the patient must receive vitamin K immediately.Rationale 3: Vitamin K is the antidote for warfarin (Coumadin) overdose and its administration is warranted with an international normalized ratio (INR) of 7-. Repeating the international normalized ratio (INR) is appropriate, but the patient must receive vitamin K immediately. Protamine sulfate is the antidote for heparin, not warfarin. Consulting the physician is appropriate, but the patient must receive vitamin K immediately.Rationale 4: Vitamin K is the antidote for warfarin (Coumadin) overdose and its administration is warranted with an international normalized ratio (INR) of 7-. Repeating the international normalized ratio (INR) is appropriate, but the patient must receive vitamin K immediately. Protamine sulfate is the antidote for heparin, not warfarin. Consulting the physician is appropriate, but the patient must receive vitamin K immediately.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-4Question 4Type: MCMAThe physician orders pentoxifylline (Trental) for the patient with peripheral vascular disease. The nurse has completed medication education and determines that learning has occurred when the patient makes which statement(s)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. "It makes my red blood cells (RBCs) squishy so they can go into the little blood vessels."2. "It decreases my platelets so my blood is less likely to clot."3. "It decreases the "stickiness" of my blood."4. "It changes how my liver makes clotting factors."5. "It thins my blood so more can get to those little vessels."Correct Answer: 1,2,3Rationale 1: Pentoxifylline (Trental) acts on red blood cells (RBCs) to reduce their viscosity and increase their flexibility to allow them to enter partially occluded vessels. Pentoxifylline (Trental) also has antiplatelet action. Pentoxifylline (Trental) decreases the viscosity or "stickiness" of blood. Pentoxifylline (Trental) is not an anticoagulant. Pentoxifylline (Trental) does not interfere with the manufacture of clotting factors in the liver.Rationale 2: Pentoxifylline (Trental) acts on red blood cells (RBCs) to reduce their viscosity and increase their flexibility to allow them to enter partially occluded vessels. Pentoxifylline (Trental) also has antiplatelet action. Pentoxifylline (Trental) decreases the viscosity or "stickiness" of blood. Pentoxifylline (Trental) is not an anticoagulant. Pentoxifylline (Trental) does not interfere with the manufacture of clotting factors in the liver.Rationale 3: Pentoxifylline (Trental) acts on red blood cells (RBCs) to reduce their viscosity and increase their flexibility to allow them to enter partially occluded vessels. Pentoxifylline (Trental) also has antiplatelet action. Pentoxifylline (Trental) decreases the viscosity or "stickiness" of blood. Pentoxifylline (Trental) is not an anticoagulant. Pentoxifylline (Trental) does not interfere with the manufacture of clotting factors in the liver.Rationale 4: Pentoxifylline (Trental) acts on red blood cells (RBCs) to reduce their viscosity and increase their flexibility to allow them to enter partially occluded vessels. Pentoxifylline (Trental) also has antiplatelet action. Pentoxifylline (Trental) decreases the viscosity or "stickiness" of blood. Pentoxifylline (Trental) is not an anticoagulant. Pentoxifylline (Trental) does not interfere with the manufacture of clotting factors in the liver.Rationale 5: Pentoxifylline (Trental) acts on red blood cells (RBCs) to reduce their viscosity and increase their flexibility to allow them to enter partially occluded vessels. Pentoxifylline (Trental) also has antiplatelet action. Pentoxifylline (Trental) decreases the viscosity or "stickiness" of blood. Pentoxifylline (Trental) is not an anticoagulant. Pentoxifylline (Trental) does not interfere with the manufacture of clotting factors in the liver.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 30-7Question 5Type: MCSAThe physician orders enoxaparin (Lovenox) for the postoperative patient. What is the best administration technique by the nurse?

1. Administer the medication in the upper arm, subcutaneously.2. Administer the medication in the abdomen, subcutaneously.3. Administer the medication via slow intravenous (IV) push in the patient's Intravenous (IV) line.4. Ask the patient where she would like the injection, and administer it subcutaneously.Correct Answer: 2Rationale 1: Administering the medication in the abdomen, subcutaneously, is the correct method of administration for enoxaparin (Lovenox). Administering the medication in the upper arm subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Asking the patient where she would like the injection and administering subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Administering the medication via slow intravenous (IV) push in the patient's intravenous (IV) line is not the correct method of administration for enoxaparin (Lovenox).Rationale 2: Administering the medication in the abdomen, subcutaneously, is the correct method of administration for enoxaparin (Lovenox). Administering the medication in the upper arm subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Asking the patient where she would like the injection and administering subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Administering the medication via slow intravenous (IV) push in the patient's intravenous (IV) line is not the correct method of administration for enoxaparin (Lovenox).Rationale 3: Administering the medication in the abdomen, subcutaneously, is the correct method of administration for enoxaparin (Lovenox). Administering the medication in the upper arm subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Asking the patient where she would like the injection and administering subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Administering the medication via slow intravenous (IV) push in the patient's intravenous (IV) line is not the correct method of administration for enoxaparin (Lovenox).Rationale 4: Administering the medication in the abdomen, subcutaneously, is the correct method of administration for enoxaparin (Lovenox). Administering the medication in the upper arm subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Asking the patient where she would like the injection and administering subcutaneously is not the correct method of administration of enoxaparin (Lovenox). Administering the medication via slow intravenous (IV) push in the patient's intravenous (IV) line is not the correct method of administration for enoxaparin (Lovenox).Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-6Question 6Type: MCMAThe patient has a deep vein thrombosis (DVT) and is admitted for initial heparin therapy. Which order(s) would the nurse want to validate with the physician?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Heparin 1,000 units intravenous (IV) every 6 hours2. Tylenol as needed (PRN) for headaches3. Obtaining a daily weight on the patient4. Advil as needed (PRN) for headaches5. Low vitamin K dietCorrect Answer: 1,4,5Rationale 1: Advil could increase the risk of bleeding. 1,000 units of heparin is a sub-therapeutic dose. Vitamin K is the antidote for warfarin (Coumadin) overdose, there is no need to restrict it with heparin therapy. Daily weights are necessary to determine medication dosage. There isn't any contraindication with heparin and Tylenol.Rationale 2: Advil could increase the risk of bleeding. 1,000 units of heparin is a sub-therapeutic dose. Vitamin K is the antidote for warfarin (Coumadin) overdose, there is no need to restrict it with heparin therapy. Daily weights are necessary to determine medication dosage. There isn't any contraindication with heparin and Tylenol.Rationale 3: Advil could increase the risk of bleeding. 1,000 units of heparin is a sub-therapeutic dose. Vitamin K is the antidote for warfarin (Coumadin) overdose, there is no need to restrict it with heparin therapy. Daily weights are necessary to determine medication dosage. There isn't any contraindication with heparin and Tylenol.Rationale 4: Advil could increase the risk of bleeding. 1,000 units of heparin is a sub-therapeutic dose. Vitamin K is the antidote for warfarin (Coumadin) overdose; there is no need to restrict it with heparin therapy. Daily weights are necessary to determine medication dosage. There isn't any contraindication with heparin and Tylenol.Rationale 5: Advil could increase the risk of bleeding. 1,000 units of heparin is a sub-therapeutic dose. Vitamin K is the antidote for warfarin (Coumadin) overdose, there is no need to restrict it with heparin therapy. Daily weights are necessary to determine medication dosage. There isn't any contraindication with heparin and Tylenol.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-8Question 7Type: MCSAThe patient is being discharged on warfarin (Coumadin) following a valve replacement. The nurse has completed medication education and determines that learning has occurred when the patient makes which statement?

1. "I must wear a MedicAlert bracelet that says I'm on warfarin (Coumadin)."2. "If I notice any bruising or bleeding I will need to have lab work done."3. "I can take enteric-coated aspirin, but not plain aspirin for my arthritis."4. "I must limit my intake of vitamin C while I'm on warfarin (Coumadin)."Correct Answer: 1Rationale 1: Patients on anticoagulant therapy should wear a MedicAlert bracelet. Aspirin is not allowed when a patient is on anticoagulant therapy. Lab work must be done routinely, not just if the patient notices bruising or bleeding. The intake of Vitamin K, not Vitamin C must be limited when a patient receives warfarin (Coumadin).Rationale 2: Patients on anticoagulant therapy should wear a medic alert bracelet. Aspirin is not allowed when a patient is on anticoagulant therapy. Lab work must be done routinely, not just if the patient notices bruising or bleeding. The intake of Vitamin K, not Vitamin C must be limited when a patient receives warfarin (Coumadin).Rationale 3: Patients on anticoagulant therapy should wear a medic alert bracelet. Aspirin is not allowed when a patient is on anticoagulant therapy. Lab work must be done routinely, not just if the patient notices bruising or bleeding. The intake of Vitamin K, not Vitamin C must be limited when a patient receives warfarin (Coumadin).Rationale 4: Patients on anticoagulant therapy should wear a medic alert bracelet. Aspirin is not allowed when a patient is on anticoagulant therapy. Lab work must be done routinely, not just if the patient notices bruising or bleeding. The intake of Vitamin K, not Vitamin C must be limited when a patient receives warfarin (Coumadin).Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 30-5Question 8Type: MCSAThe patient receives warfarin (Coumadin). The nurse plans to teach the patient to avoid which foods that are served for lunch?

1. Tomato salad with basil2. Whole-wheat bread with margarine3. Salt substitute4. Fettuccine AlfredoCorrect Answer: 1Rationale 1: Tomatoes are high in vitamin K and must be avoided when a patient receives warfarin (Coumadin). Fettuccine Alfredo is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Salt substitute is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Whole-wheat bread with margarine is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin).Rationale 2: Tomatoes are high in vitamin K and must be avoided when a patient receives warfarin (Coumadin). Fettuccine Alfredo is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Salt substitute is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Whole-wheat bread with margarine is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin).Rationale 3: Tomatoes are high in vitamin K and must be avoided when a patient receives warfarin (Coumadin). Fettuccine Alfredo is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Salt substitute is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Whole-wheat bread with margarine is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin).Rationale 4: Tomatoes are high in vitamin K and must be avoided when a patient receives warfarin (Coumadin). Fettuccine Alfredo is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Salt substitute is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin). Whole-wheat bread with margarine is not high in vitamin K so is not contraindicated when a patient receives warfarin (Coumadin).Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-8Question 9Type: MCSAThe nursing instructor is teaching student nurses about the process of hemostasis after an injury. What does the nursing instructor include as the initial event in this process?

1. Platelets become sticky.2. Plasma proteins convert to active forms.3. The vessel spasms.4. Von Willebrand's factor is activated.Correct Answer: 3Rationale 1: The blood vessel spasms, causing constriction during the initial event in the hemostasis process. Platelets do not become sticky during the initial event in the hemostasis process. Von Willebrand's factor is not activated during the initial event in the hemostasis process. Plasma proteins do not convert to active forms during the initial event in the hemostasis process.Rationale 2: The blood vessel spasms, causing constriction during the initial event in the hemostasis process. Platelets do not become sticky during the initial event in the hemostasis process. Von Willebrand's factor is not activated during the initial event in the hemostasis process. Plasma proteins do not convert to active forms during the initial event in the hemostasis process.Rationale 3: The blood vessel spasms, causing constriction during the initial event in the hemostasis process. Platelets do not become sticky during the initial event in the hemostasis process. Von Willebrand's factor is not activated during the initial event in the hemostasis process. Plasma proteins do not convert to active forms during the initial event in the hemostasis process.Rationale 4: The blood vessel spasms, causing constriction during the initial event in the hemostasis process. Platelets do not become sticky during the initial event in the hemostasis process. Von Willebrand's factor is not activated during the initial event in the hemostasis process. Plasma proteins do not convert to active forms during the initial event in the hemostasis process.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-1Question 10Type: MCSAThe patient receives enoxaparin (Lovenox) postoperatively. The nurse teaches the patient about this medication and evaluates that learning has occurred when he makes which statement?

1. "It inhibits the synthesis of prostaglandins."2. "It increases the time it takes for me to form a clot."3. "It dissolves small clots so I won't have a stroke."4. "It increases the flexibility of my blood cells."Correct Answer: 2Rationale 1: All anticoagulant drugs will increase the normal time the body takes to form clots. Enoxaparin (Lovenox) does not dissolve small clots. Enoxaparin (Lovenox) does not increase the flexibility of blood cells. Enoxaparin (Lovenox) does not inhibit the synthesis of prostaglandins.Rationale 2: All anticoagulant drugs will increase the normal time the body takes to form clots. Enoxaparin (Lovenox) does not dissolve small clots. Enoxaparin (Lovenox) does not increase the flexibility of blood cells. Enoxaparin (Lovenox) does not inhibit the synthesis of prostaglandins.Rationale 3: All anticoagulant drugs will increase the normal time the body takes to form clots. Enoxaparin (Lovenox) does not dissolve small clots. Enoxaparin (Lovenox) does not increase the flexibility of blood cells. Enoxaparin (Lovenox) does not inhibit the synthesis of prostaglandins.Rationale 4: All anticoagulant drugs will increase the normal time the body takes to form clots. Enoxaparin (Lovenox) does not dissolve small clots. Enoxaparin (Lovenox) does not increase the flexibility of blood cells. Enoxaparin (Lovenox) does not inhibit the synthesis of prostaglandins.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 30-3Question 11Type: MCSAThe patient receives heparin. During the morning assessment of the patient, the nurse notes that the patient's blood pressure and red blood cell (RBC) count are low. There is no evidence of bleeding on the bed linen or the patient's gown. What will the best assessment of this patient reveal?

1. The patient is dehydrated.2. The patient may be bleeding internally.3. The patient's activated partial thromboplastin time (aPTT) is too low.4. The patient has probably formed some clots.Correct Answer: 2Rationale 1: A low blood pressure and red blood cell (RBC) count in the patient could indicate internal bleeding. Internal bleeding, not the formation of clots, is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not a low activated partial thromboplastin time (aPTT), is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not dehydration, is most likely responsible for the low blood pressure and red blood cell (RBC) count.Rationale 2: A low blood pressure and red blood cell (RBC) count in the patient could indicate internal bleeding. Internal bleeding, not the formation of clots, is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not a low activated partial thromboplastin time (aPTT), is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not dehydration, is most likely responsible for the low blood pressure and red blood cell (RBC) count.Rationale 3: A low blood pressure and red blood cell (RBC) count in the patient could indicate internal bleeding. Internal bleeding, not the formation of clots, is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not a low activated partial thromboplastin time (aPTT), is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not dehydration, is most likely responsible for the low blood pressure and red blood cell (RBC) count.Rationale 4: A low blood pressure and red blood cell (RBC) count in the patient could indicate internal bleeding. Internal bleeding, not the formation of clots, is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not a low activated partial thromboplastin time (aPTT), is most likely responsible for the low blood pressure and red blood cell (RBC) count. Internal bleeding, not dehydration, is most likely responsible for the low blood pressure and red blood cell (RBC) count.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Learning Outcome: 30-6Question 12Type: MCSAThe patient receives an appropriate dose of warfarin (Coumadin), but the international normalized ratio (INR) is in the high range. The patient denies taking any aspirin products. What is the best assessment question to ask the patient at this time?

1. "Have you been eating much garlic?"2. "Have you been eating a lot of salads and vegetables?"3. "Have you been drinking too much milk?"4. "Are you restricting your fluids too much?"Correct Answer: 1Rationale 1: Garlic has been shown to decrease the aggregation of platelets, thus producing an anticoagulant effect. Patients taking anticoagulant medications should limit their intake of garlic. Salads and vegetables contain vitamin K, which is an antidote for warfarin (Coumadin). This would not impact the international normalized ratio (INR). Milk does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin). Dehydration does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin).Rationale 2: Garlic has been shown to decrease the aggregation of platelets, thus producing an anticoagulant effect. Patients taking anticoagulant medications should limit their intake of garlic. Salads and vegetables contain vitamin K, which is an antidote for warfarin (Coumadin). This would not impact the international normalized ratio (INR). Milk does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin). Dehydration does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin).Rationale 3: Garlic has been shown to decrease the aggregation of platelets, thus producing an anticoagulant effect. Patients taking anticoagulant medications should limit their intake of garlic. Salads and vegetables contain vitamin K, which is an antidote for warfarin (Coumadin). This would not impact the international normalized ratio (INR). Milk does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin). Dehydration does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin).Rationale 4: Garlic has been shown to decrease the aggregation of platelets, thus producing an anticoagulant effect. Patients taking anticoagulant medications should limit their intake of garlic. Salads and vegetables contain vitamin K, which is an antidote for warfarin (Coumadin). This would not impact the international normalized ratio (INR). Milk does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin). Dehydration does not impact the international normalized ratio (INR) when a patient receives warfarin (Coumadin).Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 30-5Question 13Type: MCSAA woman brings her husband to the emergency department and tells the nurse that her husband just had a stroke. The physician verifies a thrombotic cerebral vascular accident (CVA) occurred and plans to use alteplase (Activase). What priority assessment question will the nurse ask the wife?

1. "What other medications does your husband take?"2. "Does your husband have hypertension?"3. "What other medical illnesses does your husband have?"4. "What time did your husband have the stroke?"Correct Answer: 4Rationale 1: Alteplase (Activase) must be given within 3 hours of a thrombotic cerebro vascular accident (CVA) for maximum effectiveness. Asking about hypertension is a good question, but is not the priority. Asking about medications is a good question, but is not the priority. Asking about illnesses is a good question, but is not the priority.Rationale 2: Alteplase (Activase) must be given within 3 hours of a thrombotic cerebro vascular accident (CVA) for maximum effectiveness. Asking about hypertension is a good question, but is not the priority. Asking about medications is a good question, but is not the priority. Asking about illnesses is a good question, but is not the priority.Rationale 3: Alteplase (Activase) must be given within 3 hours of a thrombotic cerebro vascular accident (CVA) for maximum effectiveness. Asking about hypertension is a good question, but is not the priority. Asking about medications is a good question, but is not the priority. Asking about illnesses is a good question, but is not the priority.Rationale 4: Alteplase (Activase) must be given within 3 hours of a thrombotic cerebro vascular accident (CVA) for maximum effectiveness. Asking about hypertension is a good question, but is not the priority. Asking about medications is a good question, but is not the priority. Asking about illnesses is a good question, but is not the priority.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 30-8Question 14Type: MCSAA new mother receives heparin. She asks the nurse if she can breastfeed her baby. What is the most therapeutic response by the nurse?

1. "No, because it would be too difficult to regulate your heparin dose."2. "No, because this could cause your nipples to bleed."3. "No, because this could alter your international normalized ratio (INR) times too much."4. "No, because heparin will enter your breast milk."Correct Answer: 2Rationale 1: Use of heparin during breastfeeding can trigger bleeding from the nipples and should be avoided. Heparin does not enter the breast milk. Breastfeeding would not alter the international normalized ratio (INR). Breastfeeding would not make it difficult to regulate the heparin dose.Rationale 2: Use of heparin during breastfeeding can trigger bleeding from the nipples and should be avoided. Heparin does not enter the breast milk. Breastfeeding would not alter the international normalized ratio (INR). Breastfeeding would not make it difficult to regulate the heparin dose.Rationale 3: Use of heparin during breastfeeding can trigger bleeding from the nipples and should be avoided. Heparin does not enter the breast milk. Breastfeeding would not alter the international normalized ratio (INR). Breastfeeding would not make it difficult to regulate the heparin dose.Rationale 4: Use of heparin during breastfeeding can trigger bleeding from the nipples and should be avoided. Heparin does not enter the breast milk. Breastfeeding would not alter the international normalized ratio (INR). Breastfeeding would not make it difficult to regulate the heparin dose.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-6Question 15Type: MCSAThe patient receives warfarin (Coumadin) and becomes pregnant. The physician changes her anticoagulant to enoxaparin (Lovenox). She asks the nurse, "Why did the doctor do that?" What is the best rationale by the nurse?

1. "Because it is easier to maintain your bleeding times in a therapeutic range."2. "Because warfarin (Coumadin) is known to cause serious cardiac defects."3. "Because you are less likely to have bleeding with enoxaparin (Lovenox)."4. "Because enoxaparin (Lovenox) cannot get into your baby."Correct Answer: 4Rationale 1: Heparin and the low-molecular-weight heparin (LMWH) molecules are too large to cross the placental barrier. The patient would not be less likely to have bleeding with enoxaparin (Lovenox). Warfarin (Coumadin) is not known to cause serious cardiac defects. It is not easier to maintain bleeding times with enoxaparin (Lovenox) than with warfarin (Coumadin).Rationale 2: Heparin and the low-molecular-weight heparin (LMWH) molecules are too large to cross the placental barrier. The patient would not be less likely to have bleeding with enoxaparin (Lovenox). Warfarin (Coumadin) is not known to cause serious cardiac defects. It is not easier to maintain bleeding times with enoxaparin (Lovenox) than with warfarin (Coumadin).Rationale 3: Heparin and the low-molecular-weight heparin (LMWH) molecules are too large to cross the placental barrier. The patient would not be less likely to have bleeding with enoxaparin (Lovenox). Warfarin (Coumadin) is not known to cause serious cardiac defects. It is not easier to maintain bleeding times with enoxaparin (Lovenox) than with warfarin (Coumadin).Rationale 4: Heparin and the low-molecular-weight heparin (LMWH) molecules are too large to cross the placental barrier. The patient would not be less likely to have bleeding with enoxaparin (Lovenox). Warfarin (Coumadin) is not known to cause serious cardiac defects. It is not easier to maintain bleeding times with enoxaparin (Lovenox) than with warfarin (Coumadin).Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-6Question 16Type: MCSAThe process of fibrinolysis is to

1. stop blood flow.2. remove a blood clot.3. promote enzymes.4. increase blood flow.Correct Answer: 2Rationale 1: Fibrin stops blood.Rationale 2: Fibrinolysis is the removal of a clot in order to release plasminogen.Rationale 3: Hemostasis increases enzymes.Rationale 4: None of the clotting cascade leads to an increase in blood flow.Global Rationale: Cognitive Level: RememberingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 30-1Question 17Type: MCSAAnticoagulants are used to

1. increase the number of platelets.2. prevent the formation of blood clots.3. shorten the prothrombin time.4. dissolve blood clots.Correct Answer: 2Rationale 1: Anticoagulants do not increase the number of platelets.Rationale 2: Anticoagulants do not prevent the formation of blood clots. Rationale 3: Anticoagulants are used to prevent the enlargement of clots and do not shorten the prothrombin time.Rationale 4: Thrombolytics are used to dissolve clots.Global Rationale: Cognitive Level: RememberingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-3Question 18Type: MCSAA laboratory test used to best measure the effectiveness of warfarin sodium therapy is known as

1. complete blood count.2. platelet count.3. aPtt.4. international normalized ratio (INR).Correct Answer: 4Rationale 1: Complete blood count is not necessary for this drug.Rationale 2: Platelet count is not necessary for this drug.Rationale 3: aPtt is the best laboratory test for heparin therapy.Rationale 4: INR is the best and most effective for warfarin therapy.Global Rationale: Cognitive Level: UnderstandingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 30-4Question 19Type: MCSALaboratory studies related to heparin therapy include

1. aPtt.2. serum heparin studies.3. complete blood studies.4. sedimentation rate.Correct Answer: 1Rationale 1: aPtt is the study of choice for heparin therapy.Rationale 2: These are not valid studies.Rationale 3: Complete blood studies can be done, but are not necessarily related to heparin.Rationale 4: Sedimentation rate is not needed for heparin therapy.Global Rationale: Cognitive Level: UnderstandingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-4Question 20Type: MCSAThe most important food for a patient taking anticoagulants to avoid is

1. citrus fruits.2. garlic.3. honey.4. meat.Correct Answer: 2Rationale 1: Citrus fruits overall do not impact these drugs.Rationale 2: Garlic does interact with anticoagulants to increase their effect.Rationale 3: Honey does not interact with anticoagulants.Rationale 4: Meat has no impact on these drugs.Global Rationale: Cognitive Level: RememberingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-5Question 21Type: MCSAThrombolytic drugs are used to

1. convert plasmin to plasminogen.2. prevent the liver from making fibrin.3. prevent a thrombus from forming.4. lyse a thrombus.Correct Answer: 4Rationale 1: Thrombolytics do not convert plasmin to plasminogen.Rationale 2: Thrombolytics do not prevent the liver from making fibrin.Rationale 3: Anticoagulants, not thrombolytics, prevent the formation of a clot.Rationale 4: Thrombolytics break up the clot.Global Rationale: Cognitive Level: RememberingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-6Question 22Type: MCSAThe nurse is aware that the mechanism of action of anticoagulant drugs is to

1. alter plasma membrane and platelets.2. convert plasminogen to plasmin.3. prevent fibrin from dissolving.4. inhibit clotting factors to prevent clot formation.Correct Answer: 4Rationale 1: Antiplatelet drugs alter plasma and platelet aggregation.Rationale 2: Thrombolytics convert plasminogen to plasmin.Rationale 3: Hemostats prevent fibrin from dissolving.Rationale 4: Anticoagulants inhibit the specific clotting factors and interfere with clotting cascade, and thereby prevent clots.Global Rationale: Cognitive Level: RememberingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-7Question 23Type: MCSAA patient is taking warfarin sodium. The nurse will reinforce teaching by telling the patient that he should watch for

1. bleeding.2. pain.3. headache.4. rash.Correct Answer: 1Rationale 1: Increased risk for bleeding is the important adverse effect to teach to patients taking warfarin sodium.Rationale 2: Pain occurs with some antiplatelet drugs.Rationale 3: Headaches are not common.Rationale 4: Rash is not common.Global Rationale: Cognitive Level: UnderstandingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-8Question 24Type: MCSAThe nurse is aware that the drug that will most likely be used in the treatment of warfarin sodium overdose is

1. aspirin.2. heparin.3. vitamin K.4. protamine sulfate.Correct Answer: 3Rationale 1: Aspirin is an antiplatelet, and would lead to more bleeding.Rationale 2: Heparin would not be used; it is another drug in the class.Rationale 3: Vitamin K is the drug for overdose; it helps to clot the blood.Rationale 4: Protamine sulfate is the antidote for heparin overdose.Global Rationale: Cognitive Level: UnderstandingClient Need: Physiological Integrity

Client Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-8Question 25Type: MCMAA clinic nurse is developing a teaching handout for patients who are prescribed warfarin (Coumadin) therapy. Which statement should be included in this information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. "Tell your dentist you are taking warfarin prior to any procedures."2. "Report to the lab for testing of activated partial thromboplastin time (APTT)."3. "Avoid strenuous activities."4. "Place ice at the injection site if stinging or burning occurs."5. "Take nonsteroidal anti-inflammatories (NSAIDs) for minor pain relief."Correct Answer: 1,3Rationale 1: Warfarin increases the risk of bleeding from dental procedures.Rationale 2: APTT is not used to monitor warfarin.Rationale 3: Strenuous or risky activities place the patient at risk for injury and bleeding.Rationale 4: Warfarin is not administered by injection.Rationale 5: NSAIDs can cause bleeding if taken concurrently with warfarin.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-7Question 26Type: MCMAThe nurse is planning care for a patient receiving enoxaparin (Lovenox). Which interventions should be included?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Teach the patient or family to give subcutaneous injections at home.2. Monitor for development of deep vein thrombosis.3. Monitor multiple lab tests.4. Teach the patient signs of excessive bleeding.5. Schedule administration times right before breakfast and the evening meal.Correct Answer: 1,2,4Rationale 1: Family and patients can be taught to give subcutaneous injections at home.Rationale 2: Lovenox is used to prevent DVTs. The nurse should observe for the development of DVTs.Rationale 3: Lovenox is a low-molecular-weight heparin (LMWH), and does not require multiple lab tests.Rationale 4: Although Lovenox is more predictable than are other anticoagulants and has fewer adverse effects, bleeding is still a possibility.Rationale 5: Lovenox is generally administered once daily, and administration time is not tied to mealtimes.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-7Question 27Type: MCMAA patient is being treated for a thromboembolic disorder. If the goal is to prevent clot formation, the nurse anticipates the patient will be treated with which classification of drug?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Hemostatics2. Thrombolytics3. Anticoagulants4. Antiplatelet agents5. Clotting factor concentratesCorrect Answer: 3,4Rationale 1: Hemostatic drugs are given to inhibit fibrin destruction, thereby promoting clot formation.Rationale 2: Thrombolytic drugs are given to remove existing clots by dissolving them.Rationale 3: Anticoagulants inhibit specific clotting factors, thereby preventing clot formation.Rationale 4: Antiplatelet agents inhibit the action of platelets, thereby preventing clot formation.Rationale 5: Clotting factor concentrates replace missing clotting factors, thereby promoting clot formation.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 30-3Question 28Type: MCMAThe nurse is providing care for a patient who developed heparin-induced thrombocytopenia (HIT) during heparin therapy. The nurse is aware that lepirudin (Refludan) is often given to patients with this condition. Which assessment findings should the nurse report to the medical team?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. The most recent aPTT is 2.8.2. The patient's last stool tested positive for blood.3. The patient is allergic to eggs.4. The patient's spleen was removed after a motor vehicle accident 3 years ago.5. The patient drinks 5?6 cups of coffee daily.Correct Answer: 1,2Rationale 1: Lepirudin is contraindicated if the aPTT is above 2.5.Rationale 2: Lepirudin is contraindicated in patients who are actively bleeding.Rationale 3: There is no contraindication to the use of lepirudin in patients with egg allergy.Rationale 4: A surgery 3 years ago is not a contraindication to the use of lepirudin, nor is absence of the spleen.Rationale 5: There is no contraindication to the use of lepirudin in those who drink coffee.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-5Question 29Type: MCMAThe nurse is providing discharge teaching regarding anticoagulant therapy. Which statements by the patient would the nurse evaluate as indicating the need for further instruction?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. "I'll ask for an electric razor for my birthday next week."2. "I guess my trip to the amusement park is off for now."3. "I won't be able to cook anymore."4. "I'll get one of those new electric toothbrushes with the firm bristles."5. "I should make an appointment for a B12 injection monthly."Correct Answer: 3,4,5Rationale 1: Use of an electric razor is preferred for patients on anticoagulant therapy.Rationale 2: The patient should avoid situations in which jostling or violent bumping could occur.Rationale 3: The patient should be cautious when cutting food for preparation, but cooking is not prohibited.Rationale 4: The patient should use a soft-bristle toothbrush.Rationale 5: IM injections should be avoided.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 30-7Question 30Type: MCMAA patient has been started on ticlopidine (Ticlid) after a myocardial infarction and stent placement. How should the nurse explain the action of this medication to the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. "Ticlid will dissolve any clots that might form in your stent."2. "Ticlid will make the platelets in your blood less sticky."3. "Ticlid will change the way your platelets work their entire lives."4. "Ticlid decreases your blood's ability to clot."5. "Ticlid works just like the heparin you have been on in the hospital."Correct Answer: 2,3,4Rationale 1: Ticlid does not act to dissolve clots.Rationale 2: Ticlid is an adenosine diphosphate (ADP) receptor blocker that acts to make platelets unable to aggregate, thus rendering them less "sticky."Rationale 3: Ticlid causes irreversible changes in platelet plasma membranes.Rationale 4: Ticlid does decrease the blood's ability to clot.Rationale 5: The mechanisms of action of Ticlid and heparin are not alike.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-3Question 31Type: MCMAA patient who has hemophilia A is scheduled for a minor surgical procedure. The patient states, "I'm worried about this surgery. My doctor told me I had to come to the hospital for some kind of treatment a week before it. What is that all about?" How should the nurse respond?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. "You must have misunderstood the directions. Let me check with the health care provider."2. "Blood will be taken and banked in case you need to have it retransfused on the day of surgery."3. "You will be given a test dose of a medication used to increase your clotting factors."4. "This visit is related to your hemophilia and keeping you safe during the surgery."5. "Don't be worried about the testing. Nothing will hurt."Correct Answer: 3,4Rationale 1: The patient has not misunderstood the directions provided by the health care provider.Rationale 2: Preparation for auto-transfusion is not the purpose of this visit.Rationale 3: Desmopressin therapy can cause an increase in Factor VIII levels. A test dose is given one week prior to minor surgery to determine if the patient is responsive to the drug.Rationale 4: Simple answers that assure the patient that his or her safety is being protected are useful when working with patients whose anxiety is elevated.Rationale 5: The nurse has not answered the patient's concerns.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 30-7Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.