1. DVT cases

2.  Heparin, low molecular weight heparin, or fondaparinux are usually continued for at least five days, along with another medication called warfarin (Coumadin).fondaparinuxwarfarin  Warfarin is a pill that is taken by mouth. After approximately five days, the heparin, low molecular weight heparin or fondaparinux are discontinued while the warfarin is continued for at least three months

3.  For patients taking warfarin, the clotting factors in the blood need to be measured on a regular basis with a blood test called the International Normalized Ratio (INR). The target level INR for people on warfarin is usually between 2 and 3warfarin  Patients with cancer should be treated with an LMWH for at least 6 months

4.  Duration of treatment — Anticoagulation is recommended for a MINIMUM of three months in a patient with DVT.  Walking during DVT treatment — Once an anticoagulant has been started and symptoms (eg, pain, swelling) are under control, the person is strongly encouraged to get up and walk around. Studies show that there is no increased risk of complications (eg, pulmonary embolus) in people who get up and walk, and walking may in fact help the person feel better faster.

5.  Thrombolytic therapy — In some cases, a healthcare provider will recommend an intravenous medicine to dissolve blood clots. This is called thrombolytic therapy. This therapy is reserved for patients who have serious complications related to PE or DVT, and who have a low risk of serious bleeding as a side effect of the therapy.  The response to thrombolytic therapy is best when there is a short time between the diagnosis of DVT/PE and the start of thrombolytic therapy.

6.  A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? A. "Administration of two anticoagulants reduces the risk for recurrent venous thrombosis." B. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring." C. "The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation." D. "Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant."

7.  c Low molecular weight heparin, LMWH, is used because of the immediate effect on coagulationand discontinued once the international normalized ratio, INR, value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE.)

8.  The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says, A. "I should reduce the amount of green, leafy vegetables that I eat." B. "I should wear a Medic Alert bracelet stating that I take Coumadin." C. "I will need to have blood tests routinely to monitor the effects of the Coumadin." D. "I will check with my health care provider before I begin or stop any medication."

9.  a (Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are highin vitamin K, such as green, leafy vegetables. The other patient statements are accurate)

10.  A patient is admitted with venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse assess while the patient is receiving this medication? A. International normalized ratio (INR) B. Activated partial thromboplastin time (APTT) C. Anti-factor Xa D. Platelet count

11.  b (Rationale: Unfractionated heparin can be given by continuous intravenous, IV, for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time, aPTT.)

12.  The nurse instructs a patient with a pulmonary embolism about enoxaparin (Lovenox). Which statement by the patient indicates understanding about the instructions? a. "The medicine will dissolve the clot in my lung." b. "I need to take this medicine with meals." c. "The medicine will be prescribed for 10 days." d. "I will inject this medicine into my abdomen."

13.  c (Rationale: Enoxaparin is a low-molecular weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents, e.g., tissue plasminogen activator or alteplase, will dissolve an existing clot. Enoxaparin is administered subcutaneously by injection.)

14.  A patient at the highest risk for venous thromboembolism, VTE, is: A. a 62 year old man with spider veins who is having arthroscopic knee surgery B. a 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe C. a 26 year old woman who is 3 days postpartum and received maintenance IV fluid for 12 hours during her labor D. an active 72 year old man at home recovering from transuerthral resection of the prostate for benign prostatic hyperplasia

15.  b (Rationale: Three important factors, called Virchow's triad, in the etiology of venous thrombosis are, 1, venous stasis, 2, damage of the endothelium, inner lining of the vein, and, 3, hypercoagulability of the blood. The patient at risk for venous thrombosis usually has predisposing conditions for these three disorders.  The 32-year-old woman has the highest risk: long trips without adequate exercise, venous stasis, cigarette smoking, and use of oral contraceptives (especially in women older than 35 years who smoke, the likelihood of hypercoagulability of blood is increased.)

16.  A 72 yr old male client has a total hip replacement for long- standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: A. Pneumonia B. Hemorrhage C. Wound Infection D. Pulmonary Embolism

17.  d (A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow)

18.  Identify the factor of Virchow's triad present in each of the following conditions associated with venous thromboembolism (VTE). IV therapy A. damage to the endothelium B. venous stasis C. hypercoagulability

19.  Identify the factor of Virchow's triad present in each of the following conditions associated with venous thromboembolism (VTE). Prolonged immobilization A. damage to the endothelium B. venous stasis C. hypercoagulability

20.  Identify the factor of Virchow's triad present in each of the following conditions associated with venous thromboembolism (VTE). Estrogen therapy A. damage to the endothelium B. venous stasis C. hypercoagulability

21.  To help prevent embolization of the thrombus in a patient with VTE, the nurse teaches the patient to do what? A. dangle the feet over the edge of the bed q2-3hr B. ambulate for short periods three to four times a day C. keep the affected leg elevated above the level of the heart D. maintain bed rest until edema is relieved and anticoagulation is established

22.  D (Prevention of emboli formation can be achieved by bed rest and limiting movement of the involved extremity until the clot is table, inflammation has receded and anticoagualtion is achieved. Elevating the affected limb promote venous return, but it does not prevent embolization, and dangling the legs promotes venous stasis and further clot formation)

23.  The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. The best response by the nurse is... A. "The drug will break up and dissolve the clot so that circulation in the vein can be restored." B. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed." C. "Heparin won't dissolve the clot, but it will inhibit the inflammation around the clot and delay the development of new clots." D. "The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs."

24.  b (Anticoagulation therapy with heparin or warfarin, coumadin, does not dissolve clots but prevents propagation of the clot, development of new thrombi, and embolization; lysis of the clot occurs through the action of the body's intrinsic fibrinolytic system or by the administration of fibrinolytic agents.)

25. Patients should be monitored for resolution of symptoms, the development of recurrent thrombosis, and symptoms of the post thrombotic syndrome, as well as for adverse effects from the treatments Hemoglobin, hematocrit, and blood pressure should be monitored carefully to detect bleeding from anticoagulant therapy.

26. Coagulation tests (aPTT, PT, INR) should be performed prior to initiating therapy to establish the patient’s baseline values and guide later anticoagulation. Outpatients taking warfarin should be questioned about medication adherence and symptoms related to bleeding and thromboembolic complications. Any changes in concurrent medications should be carefully explored.