Charter College, Anchorage - NURSING NU1005

Chapter 20: Drugs That Affect Blood Clotting

Workman & LaCharity: Understanding Pharmacology: Essentials for Medication Safety, 2nd Edition

MULTIPLE CHOICE

BASIC CONCEPTS

1)Which blood component forms the initial plug that helps stop bleeding?

1. 1. Fibrin
   2. Platelets
   3. Neutrophils
   4. Eosinophils

2. Which patient factor increases the risk for bleeding during anticoagulant therapy?
   1. Pregnancy
   2. Recent major surgery
   3. History of severe arthritis
   4. Uncontrolled low blood pressure

3. What is the name of a blood clot that forms and stays within a blood vessel or the heart?
   1. Antibus
   2. Embolus
   3. Thrombus
   4. Coagulus

4. Which category of drugs actually dissolves existing clots?

1. 1. Heparins
   2. Coagulants
   3. Antiplatelets
   4. Thrombolytics

5. Which thrombin inhibitor can be given by subcutaneous injection?
   1. Heparin
   2. Argatroban
   3. Lepirudin
   4. Bivalirudin

6. What is the most common purpose of the international normalized ratio (INR)?
   1. Measuring the total amount of blood a person has
   2. Reporting the results of warfarin anticoagulation
   3. Assessing the number of clotting factors present
   4. Determining the number of platelets

7. Which category of anticoagulant drugs includes warfarin (Coumadin)?
   1. Platelet inhibitors
   2. Heparin inhibitors
   3. Thrombin inhibitors
   4. Clotting factor synthesis inhibitors

8. What is the intended response of clotting factor synthesis inhibitor drugs?

1. 1. Increased clotting times
   2. Decreased clotting times
   3. Increased platelet counts
   4. Decreased platelet counts

9. What health problem is a possible adverse effect of any drug that reduces blood clotting?
   1. Pulmonary embolism
   2. Hemorrhage
   3. Thrombosis
   4. Diabetes

10. Which common over-the-counter agent is an antiplatelet drug?
    1. Aspirin
    2. Tylenol
    3. Vitamin C
    4. Magnesium

11. What type of clotting problem is most often treated with a thrombin inhibitor?
    1. Hemophilia
    2. Hemorrhage
    3. Heart attack
    4. Gastric ulcers

12. What is the intended response to an erythropoiesis-stimulating agent (ESA)?
    1. Increased red blood cell counts
    2. Decreased red blood cell counts
    3. Increased platelet counts
    4. Decreased platelet counts

13. What health problem is a possible side effect of erythropoiesis-stimulating agent (ESA) therapy?
    1. Increased risk for infection
    2. Low blood pressure
    3. Hypertension
    4. Anemia

14. For what specific health problem is urokinase (Abbokinase) approved?
    1. Acute myocardial infarction (heart attack) in which the symptoms began 24 hours ago
    2. Stroke caused by an embolus lodged in a small artery in the brain
    3. Stroke caused by a ruptured blood vessel in the brain
    4. Massive acute pulmonary embolism

ADVANCED CONCEPTS

15. How do antiplatelet drugs work?
    1. Increasing the elimination of formed platelets
    2. Decreasing the formation of new platelets
    3. Preventing platelets from aggregating
    4. Trapping platelets in the spleen

16. How are anticoagulant drugs and thrombolytic drugs different?
    1. There is no difference; they both have the same actions.
    2. Anticoagulants prevent clots from forming whereas thrombolytics can dissolve clots that have already formed.
    3. Thrombolytics must be administered intravenously while all anticoagulants are administered as oral agents.
    4. Anticoagulants prevent clots by actually thinning the blood whereas thrombolytics reduce platelet aggregation and do not affect blood thickness.

17. Which condition occurs as a result of a thrombus developing in a coronary artery?
    1. Cerebrovascular accident
    2. Deep vein thrombosis
    3. Pulmonary embolus
    4. Myocardial infarction

18. A patient asks why an anticoagulant has been prescribed. What is your best response?
    1. “It will dissolve any clots in your blood vessels.”
    2. “It will prevent any new clots from forming.”
    3. “It will prevent a clot from migrating.”
    4. “It will thin your blood.”

19. A patient prescribed an anticoagulant long term engages in all of the following activities. Which activity do you teach the patient to avoid?
    1. Golfing
    2. Bowling
    3. Jumping rope
    4. Walking 2 miles daily

20. A patient in the emergency department developed stroke symptoms 1 hour ago. Which type of drug should you expect to prepare to resolve this problem?
    1. Thrombolytic
    2. Thrombin inhibitor
    3. Antiplatelet drug
    4. Clotting factor synthesis inhibitor

21. Which action should you avoid performing on a patient after he or she has received a thrombolytic drug?
    1. Administering IV drugs
    2. Using electric razors
    3. Providing a soft toothbrush
    4. Giving an intramuscular injection

22. A patient who has been prescribed continuous intravenous (IV) heparin asks why being weighed is necessary. What is your best response?

1. 1. “All patients are weighed upon admission to the hospital.”
   2. “IV heparin has been known to cause weight gain.”
   3. “The initial IV bolus of heparin is prescribed based on your weight.”
   4. “The rate of the heparin infusion is based on your weight.”

23. The aPTT of a patient who is prescribed continuous intravenous (IV) heparin is two times the control value. What is your best action?
    1. Increase the IV rate as ordered.
    2. Decrease the IV rate as ordered.
    3. Leave the rate unchanged.
    4. Stop the infusion and notify the prescriber.

24. A patient is being discharged on enoxaparin (Lovenox). Which statement should you include in the discharge teaching plan?
    1. “An advantage of this drug is that labs do not need to be drawn to guide therapy.”
    2. “Follow-up lab work must be drawn every 2 to 6 months.”
    3. “Enoxaparin is given intramuscularly twice a day.”
    4. “The purpose of this drug is to dissolve clots.”

25. A patient who has been receiving heparin subcutaneously for 3 weeks has all of the following laboratory blood test values. Which value should you report immediately to the prescriber?
    1. Activated partial thromboplastin time 1.5
    2. International normalized ratio (INR) 1.7
    3. Red blood cells 4.2 million/mm³
    4. Platelets 20,000/mm³

26. A patient is taking warfarin (Coumadin) daily to prevent blood clots from forming in deep veins. Which statement made by the patient indicates that more teaching is needed about this therapy?
    1. “I have been eating more salads and other green, leafy vegetables to prevent constipation.”
    2. “I have been using acetaminophen (Tylenol) instead of aspirin for pain.”
    3. “Instead of a safety razor, I have been using an electric shaver.”
    4. “On hot days, I make sure to drink at least two quarts of water.”

27. A patient has been discontinued from warfarin (Coumadin) therapy for 3 weeks. Which laboratory test indicates that all effects of the warfarin have been eliminated?
    1. International normalized ratio (INR) of 0.9
    2. Red blood cell count of 5 million/mm³
    3. Hemoglobin of 16 g/dL
    4. Hematocrit of 42%

28. A patient with a vein thromboembolism is ordered to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is your best action?
    1. Administer the two drugs as prescribed.
    2. Remind the prescriber that two anticoagulants should not be administered concurrently.
    3. Hold the dose of warfarin until the patient’s activated partial thromboplastin time is the same as the control value.
    4. Monitor the patient for clinical manifestations of internal or external bleeding at least every 2 hours.

29. Why is warfarin (Coumadin) avoided during pregnancy?
    1. Warfarin can induce premature closure of the foramen ovale in the fetus.
    2. The fetal and newborn liver cannot metabolize warfarin and anemia results.
    3. The fetus and newborn are more likely to have allergic reactions to warfarin.
    4. Warfarin crosses the placenta and causes birth defects or hemorrhage in the fetus.

30. A patient prescribed subcutaneous heparin tells you that her menstrual bleeding is heavier than usual. What is your best response?
    1. “I will hold the drug and notify your prescriber.”
    2. “This is a fairly common and expected side effect of the drug.”
    3. “Heavy bleeding is a concern because you might become anemic.”
    4. “I will have to give you a shot of protamine sulfate to reverse the drug’s action.”

31. A patient who has been on warfarin (Coumadin) therapy for a year calls to tell you he forgot to take the drug yesterday. What is your best advice?
    1. “Take today’s dose as usual.”
    2. “Take the forgotten dose right now and take today’s dose at the usual time.”
    3. “Come to the clinic to receive an injection of warfarin as soon as possible.”
    4. “Take today’s dose as usual and also take an 81 mg tablet of aspirin at the same time.”

32. Which blood test should be performed on a regular basis for a patient who takes an oral direct thrombin inhibitor daily?
    1. International normalized ratio (INR)
    2. Complete blood cell count
    3. Potassium
    4. Sodium

33. A patient who delivered a baby 6 weeks ago is now prescribed low-molecular-weight heparin for a venous thrombosis in her leg. She asks whether she can continue to breastfeed her baby while taking this drug. What is your best response?
    1. “Yes, the baby’s digestive system will inactivate the drug.”
    2. “Yes, the drug does not pass into breast milk.”
    3. “No, the drug will increase the baby’s risk for bleeding.”
    4. “No, the drug can delay your baby’s growth and development.”

34. Which statement by a patient who is prescribed heparin indicates the need for additional teaching?
    1. “I’ll be sure to have my follow-up aPTT drawn when the prescriber tells me to.”
    2. “I will not take over-the-counter drugs that contain aspirin.”
    3. “I will get plenty of exercise playing soccer.”
    4. “I’ll tell my prescriber if I have headaches.”

35. Which dietary teaching do you include for a patient who is prescribed warfarin (Coumadin) on discharge?
    1. “Weight loss diets such as the Atkins diet are OK while taking this drug.”
    2. “Be sure to eat lots of green leafy vegetables for extra vitamin K.”
    3. “Dietary changes do not affect the action of this drug.”
    4. “Drinking alcoholic beverages can change the action of warfarin.”

36. Which antiplatelet drug prevents platelet aggregation by blocking a receptor on the surface of platelets?
    1. Aspirin
    2. Acetaminophen (Tylenol)
    3. Clopidogrel (Plavix)
    4. Dipyridamole

37. When should antiplatelet drugs be administered?
    1. With or just after a meal
    2. At bedtime to prevent light-headedness
    3. At the same time as an oral antacid
    4. One hour before or 2 hours after a meal

38. A patient who received the thrombolytic drug alteplase (Activase) asks why continuous heparin is now infusing intravenously. What is your best response?
    1. “There may be additional clots in your body and we want to be sure they are all dissolved.”
    2. “Once the clot is dissolved, heparin is given continuously to prevent any new clots from forming.”
    3. “The heparin finishes the job of dissolving the clot that the alteplase started.”
    4. “Heparin is infused continuously in case we need to give additional dosages of alteplase.”

39. Why are erythropoiesis-stimulating agents (ESAs) prescribed for patients with chronic kidney disease?
    1. To protect the kidney from further hypoxic damage during anemia episodes.
    2. To improve blood cell counts and reduce the need for blood transfusions.
    3. To prevent vein thromboembolism during periods of dehydration.
    4. To reduce the risk of uric acid precipitation and renal failure.

40. A patient coming to the clinic for a weekly infusion of darbepoetin alpha (Aranesp) has all of the following changes. For which change should you hold the dose of the drug?
    1. Weight loss of 5 lb
    2. Hemoglobin increase from 8 to 10 g/dL
    3. Blood potassium increase from 3.8 to 4.8 mEq/L
    4. Blood pressure increase from 126/80 to 148/92 mm Hg

41. A patient who has been self-injecting epoetin alfa (Procrit) three times weekly for anemia now reports all of these problems. For which one do you tell him or her to call 911?
    1. Fever and chills
    2. Drooping on the right side of the face
    3. 3 lb weight gain over the past 2 weeks
    4. Intermittent pain and redness at the injection site

42. A patient is receiving oprelvekin (Neumega) subcutaneously daily. Which laboratory value indicates that the therapy is effective?
    1. Hemoglobin 12 g/dL
    2. Platelet level 55,000/mm³

1. 3. Red blood cells 4.5 million/mm³
   4. International normalized ratio (INR) 1.0

MULTIPLE RESPONSE ADVANCED CONCEPTS

1. Which techniques should you perform to prevent excessive bleeding when administering an intramuscular injection to a patient who is on anticoagulation therapy? (select all that apply)
   1. Using the smallest possible injection needle
   2. Injecting the drug slowly, over at least a 60-second period
   3. Applying pressure to the site for at least 5 minutes after the injection
   4. Ensuring that the needle is placed within a previous injection puncture site
   5. Cleansing the skin at the injection site for at least 30 seconds before the injection
   6. Applying warm compresses to the site for at least 15 minutes after the injection

2. What actions are performed when giving a subcutaneous injection of low-molecular-weight heparin? (select all that apply)
   1. Position the patient lying down.
   2. Expel the air bubble before injection.
   3. Insert the needle into a skinfold held between the thumb and forefinger.
   4. Release the skinfold then inject the drug.
   5. Rub the injection site to avoid bruising.

3. Which factors are absolute contraindications for thrombolytic therapy? (select all that apply)
   1. Active peptic ulcer disease
   2. Active internal bleeding
   3. Recent head trauma
   4. Endocarditis
   5. Suspected aortic aneurysm
   6. Surgery within the last 10 days

COMPLETION

ADVANCED CONCEPTS

1. A patient is prescribed 15,000 units/mL of heparin subcutaneously. The drug on hand is heparin 20,000 units/mL. How many milliliters should you administer?

           mL

2. A patient is prescribed 300 mg of oral clopidogrel (Plavix) as a first dose. The drug on hand is clopidogrel 75 mg. How many tablets should you give?

3. A child who weighs 48 lb has been ordered warfarin (Coumadin) 0.1 mg/kg. The available drug is 1 mg/scored tablet. How many tablets will you give this child?