Difficulty. Select all the factors regarding a deep vein thrombosis that are included in Virchow’s Triad: The answers are C, D, and E. Virchow’s Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Compression stockings may prevent PTS (post-thrombotic syndrome), which happens sometimes after the development of a DVT. Pulmonary embolism due to deep vein thrombosis (DVT). NCLEX Review Questions Chapter 37 From Evolve Resources III. 1. The answers are B, C, and D. Virchow’s Triad details the THREE factors for blood clot formation within the vessel. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. 9. Created by. What are some conditions that cause an increased risk of forming a clot within the vessel? What factors play a role in the development of a DVT? A. Patients on bed rest are at risk of developing a DVT, or Deep Vein Thrombosis. A pulmonary embolism is a risk from the development of a DVT. Once a DVT has developed it could result in a pulmonary embolism (PE). This causes WBCs, RBCs, and platelets to stick together within the vein. So think of anything that damages the lining inside the vessel. Option C is wrong because it should say:  “A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.”. These devices wrap around the legs and inflate and deflate to help move blood flow (similar to walking). What are the risk factors for developing a deep vein thrombosis (DVT)? The answers are B, D, G. Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). See our full. The legs are the most common sites of DVT. A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. Quiz Flashcard. This is because vein valves and walls became damaged due to the clot…blood doesn’t flow in the right directions (back to the heart). Compression stockings per MD order: provides a specific amount of compression to help decrease risk of blood clot development. Enhances the activity of antithrombin III, which will inhibit thrombin and the conversion of fibrinogen to fibrin. Based on Virchow’s Triad, select which patients below are at RISK for the development of a deep vein thrombosis? One of the two subsections of the Safe and Effective Care Environment category is “Management of Care.” Match. What signs and symptoms below would possibly indicate a deep vein thrombosis is present? What nursing intervention below would the nurse NOT include in the patient’s plan of care to prevent DVT formation? If the vein’s valves are damaged or the muscles aren’t working (or being used) blood isn’t going to flow back very well and a blood clot can develop. If the aPTT is too low, blood clots can form.  If the aPTT is too high, bleeding can occur. DVT (Deep Vein Thrombosis) NCLEX Questions DVT (deep vein thrombosis) NCLEX questions for nursing students! D-dimer can be reported in fibrinogen equivalent units (FEU) or d-dimer units (DDU). A. If the blood clot becomes bigger it may break off and travel in blood circulation. To answer that question, we must review Virchow’s Triad. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. 1. This NCLEX review video is on preventing DVTs. Nurse Plus is … It can lead to FALSE positives. ), Medications that are damaging to the vein. All Rights Reserved. This Quiz has 12 questions. 13. "The calf is touched for temperature and firmness, and observed for redness," says Curran Krupar , RN, ED nurse at EMH Medical Center in Elyria, OH. This includes: DVTs tend to occur in the lower extremities (legs), but can occur in the upper extremities as well. Used to diagnose blood clots or Disseminated Intravascular Coagulation (DIC). Virchow’s Triad gives us three main factors that can lead to blood clot formation within a vein. The nurse should: We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. Deep vein thrombosis is a condition in which - 1/12. There are two types of veins in the leg: superficial veins which lie just below the skin and can be seen on the surface, and deep veins which lie deep within the leg muscles. Endothelial damage to the vein: This endothelial is a layer of cells that lines the inside of the vein. Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. A deep vein thrombosis (DVT) is a blood clot that forms within the vein. DVT (deep vein thrombosis) NCLEX questions for nursing students! A patient’s D-dimer result is <500 ng/mL. (acts fast) given IV or subq…weight-based, Monitor aPTT (activated partial thromboplastin time): 1.5 to 2.5 times normal ranges, >80 seconds risk for bleeding….dose decreased, <60 seconds NOT therapeutic…risk for clots and may need dosage increased. Therefore, the nurse would NOT just apply them at bedtime but during the day too. NCLEX Review: DVT – Prevention and Treatment. 7. 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Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high. If you find benefit from our efforts here, check out our premium quality NCLEX study guide to take your studying to the next level. [10 questions] The highest systemic blood pressure is found in the: Aorta Capillaries Arterioles Circle of Willis. Patients who experience sepsis are at risk for hypercoagulability of the blood. It prevents blood clots from forming, and if one is present, it will help prevent it from becoming bigger. Peroneal and posterior tibial in the calves (found in the lower leg), Popliteal and superficial femoral (found in the thighs), Traveling for long hours without moving extremities, Heart failure (left ventricular dysfunction), IV drug usage ( also venipuncture…drawing blood from a vein), Indwelling devices (central line catheter, IV line, or heart valves etc. Damage to this layer can be from a direct or indirect cause, but regardless it stimulates platelets and the coagulation process. A. A. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein in the leg or arm. However, the MD must further investigate if the patient has a DVT. Take this quiz with these sample exam questions on peripheral vascular disease to see how you score! B. In order for this medication to have a therapeutic effect on the patient, the aPTT should be? Apply cool compresses to affected extremity, D. Elevate affected extremity above heart level, H. Apply sequential compression device (SCD) to the affected extremity. Deep vein thrombosis can cause leg pain or swelling, but also can occur with no symptoms.Deep vein thrombosis can develop if you have certain medical conditions that affect how your blood clots. With NCLEX-style practice questions, essential nursing content organized according to the test plans and reinforcement activities, you'll be well on your way to success. However, DVTs in the lower extremities tend to have a higher chance of breaking off and turning into a PE (pulmonary embolism). … Nursing Study Guide for Deep Vein Thrombosis. 10. Diagnosis and Treatment of Venous Thromboembolism | CDC. STUDY. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin. A. Don’t forget to check out the other NCLEX review quizzes in this series and to watch the lecture on deep vein thrombosis before taking the quiz. Spell. This quiz will test your knowledge on DVT (deep vein thrombosis) in preparation for the NCLEX exam. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein in the leg or arm. What are some conditions that cause damage the endothelial lining? Leg circumference measurement (calf)…measure about 10 cm or 4 inches below tibial tuberosity…watch out for a 3 cm circumference or more measurement when compared to the non-affected calf. According to Virchow’s Triad, a blood clot can form within the vein for several reasons. It takes about 3-5 days of scheduled doses to start achieving a therapeutic INR level. These devices can come unplugged from wall and quit working. A deep vein thrombosis is a type of venous thromboembolism (VTE). What is your next nursing action per protocol? Homan’s Sign is NOT a reliable method for assessing for a DVT. Checking your knowledge of deep vein thrombosis is possible thanks to this quiz/worksheet combo. The site provides NCLEX-RN and NCLEX-PN questions that are based on the materials developed by 2020 National Council of State Boards of Nursing and are similar to those you’ll find on the official exam. Which statement below is incorrect about a deep vein thrombosis (DVT)? Which … So we’ve seen how a clot forms now let’s talk about what you can see in your patient that may have a DVT. Text Mode – Text version of the exam 1. Clotting factors cause fibrin to be created. mt6399. The answers are A and D. Warfarin (Coumadin) does NOT dissolve blood clots. As the nurse, you will want to be familiar with the prevention of a blood clot (venous thromboembolism VTE), management of a DVT, and anticoagulation therapy. Which option below is considered a positive Homan’s Sign for the assessment of a deep vein thrombosis (DVT)? So, when they start to work within the vessel it recruits other chemicals called clotting factors. Also, a positive result doesn’t necessarily mean the patient has a clot because some disease processes can cause a false positive. The main reason for this is due to a disease process, but it can be due to other reasons. (NOTE: When you hit submit, it will refresh this same page. During the Quiz End of Quiz. Please do not copy this quiz directly; however, please feel free to share a link to this page with students, friends, and others. C. The nurse will administer per physician’s order Enoxaparin in the subcutaneous tissue of the abdomen. Anyone can develop a deep vein thrombosis, especially if these risk factors are present. Questions. You’re educating a patient about Warfarin (Coumadin) and how it is used to treat blood clots. In this 20-item NCLEX style exam, you knowledge about the different Peripheral Vascular Diseases will be challenged. Also, a normal d-dimer is <500 ng/mL (FEU). This forms a clot and it continues to grow, which can eventually break off and enter venous circulation. Veins located in the pelvis, lower leg (calf), and thighs. This website provides entertainment value only, not medical advice or nursing protocols. 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Teach patient to perform exercises by flexing and extending feet and legs every hour while awake. Continue with the infusion because no change is needed based on this aPTT. DVT Deep Vein Thrombosis Nursing Diagnosis Interventions NCELX Review and Care Plans. A nurse is advising a patient with Chronic Fatigue Syndrome on infection control procedures. Increase the drip rate per protocol because the aPTT is too low. This is a protein fragment that hangs out in the blood when a clot breaks down. To improve patient outcomes nurses should focus on preventing DVT. However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU). ... A client is being discharged home from the hospital after being treated for a deep vein thrombosis (DVT). The nurse will apply sequential compression devices (SCDs) per physician’s order to the patient’s lower extremities every night at bedtime. The answer is A. Homan’s Sign is NOT reliable because of false positives, but know for exams how to elicit a response. Fibrin causes the big problem in terms of a clot developing because fibrin is like strands of mesh. This is the first of our 3 free practice tests. Do you think you could pass the NCLEX? sudden shortness of breath, decreased oxygen saturation, fast heart rate, chest pain, very anxious, sweating, coughing, Fitted and applied properly as prescribed. This is a blood test that assesses for fibrin degradation fragment (d-dimer), it’s a fibrin degradation product. 6,000 Practice NCLEX Questions; Join Now. Prevention…very simple but so beneficial…nurses play a HUGE role with this! The answer is B. Hypercoagulability: let the name of this factor help you…hyper means increase or high and coagul refers to the coagulation process in the body (hence forming a clot). Deep Vein Thrombosis (DVT) NCLEX Review. Since it’s a Vitamin K antagonist, it will work to inhibit clotting factors from using Vitamin K. 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