NRNP 6566 Week 5 Knowledge Check (Version 1)
Question: Renee is a 56-year-old female that fell about a week ago and … her R ankle. She states she has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she … that her calf was sorer than it had b...
question renee is a 56 year old female that fell about a week ago and … her r ankle she states she has been taking
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Question 1
Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She
states she has been taking it easy and laying around her home for most of the last week
so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R
foot and ankle were more swollen than they had been. She came to urgent care today
because she was afraid that the injury was worse than she thought it was.
T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds
Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft
R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some
discomfort in the ankle and calf area.
Pedal pulses equal bilaterally
The APRN orders a duplex ultrasound of the right leg. Radiology reports that the
ultrasound is positive for a deep vein thrombosis. How would you manage this patient
(include labs and meds)?
Correct
Answer: It is appropriate to treat her on an outpatient basis with appropriate
education and support.
Obtain baseline PT/INR, PTT, CBC labs
Begin Xarelto 15 mg po bid
Patient education on medication and potential complications – return to
emergency department for new onset shortness of breath
Question 2
A 26-year-old female is currently on Lovenox 80 mg subq daily. What labs should the
APRN order to monitor this patient?
Correct
Answer: Enoxaparin (Lovenox) is a form of heparin but its action does not affect any of
the clotting studies (PTT or PT/INR) so there is no value in monitoring them.
Low molecular weight heparin and fractionated heparin can cause heparin
induced thrombocytopenia (HIT), Monitoring for enoxaparin (Lovenox) would
include platelet counts to assess for HIT which can occur as soon as 3 days
after the medication is initiated.
Question 3
A 64-year man is recovering from a transurethral resection of the prostate for treatment
of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the
urinary tract infection. The post-operative course has been smooth and the APRN is
removing the 3-way Foley catheter when there is a sudden release of bright red blood
with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic
and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was
immediately transferred to the surgical intensive care unit (SICU) and a stat hematology
consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin
time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were
drawn. Results were:
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, CBC with markedly decreased platelet count, peripheral blood smear showed decreased
number of platelets and presence of large platelets and fragmented red cells
(schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The
d-dimer was markedly elevated, and fibrinogen level was low.
Based on the clinical presentation and laboratory data provided, what is your working
diagnosis?
Correct
Answer: Disseminated intravascular coagulation (DIC) is the most likely diagnosis. DIC
can result from numerous clinical conditions, including sepsis, trauma,
obstetric, emergencies, and malignancy.
The presence of schistocytes (fragmented red blood cells) on the peripheral
blood smear suggests red blood cell injury from damaged endothelium.
Decreased platelet count and low fibrinogen would distinguish DIC from
thrombotic thrombocytopenic purpura and hemolytic anemia.
Question 4
A 66-year-old man is taking warfarin due to his atrial fibrillation. He noted that his gums
were bleeding yesterday while eating. Today he had a coughing spell and has been
spitting up bright red blood ever since. The APRN is called by the ER with the result of the
INR ordered. The INR is 9.8. What is the appropriate treatment of this patient?
Correct
Answer: The 2019 Chest guideline offers some specific guidance in the management of
VKA (vitamin K antagonist). If the INR is 4.5 -10 with no evidence of bleeding,
the recommendation is to hold the medication but NOT administer any vitamin
k or other reversal agents. If there is bleeding (as in this patient), the guideline
recommends rapid reversal with four factor prothrombin complex (PCC) rather
than with plasma. In addition, 5-10 mg of vitamin K by slow IV injection in
addition to the PCC.
Question 5
A 64-year-old man diagnosed with a pulmonary embolism is currently on warfarin. His INR
readings have been very inconsistent, and the decision is made to change his medication
to Rivaroxaban (Xarelto). What dose should be initiated and how would you discontinue
the warfarin?
Correct
Answer: Warfarin should be discontinued. Once the INR reaches 2.0 or below, Xarelto
15 mg bid x 3 weeks would be initiated. After 3 weeks, the dose is changed
to 20 mg daily.
Question 6
A 66-year-old man was evaluated for shortness of breath for the last three months.
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