2.

In too deep

ANCC/AACN
CONTACT HOURS

Understanding deep vein thrombosis

Two million people will experience some

form of deep vein thrombosis, or DVT,
this year, so its easy to see why DVT is
such an important topic. Well give you
the tools you need to understand DVT
from how it happens and whos at risk
to what you can do to help these
patients.
JAMES STOCKMAN, RN, CCRN, BSN
Staff Nurse Trinity Mother Frances Health
System Tyler, Tex.
The author has disclosed that he has no significant relationships with or financial interest in any commercial companies
that pertain to this educational activity.

DEEP VEIN THROMBOSIS

(DVT) is a clot that forms most
commonly within the deep
veins of the legs, but it can also
occur in the pelvis or arms.
DVT has been increasingly in
the spotlight for the last 15
years due to three factors: the
rising cost of health care, an increase in preventive medicine,
and our aging population.
In this article, Ill fill you in on
DVT, including what you need
to know about taking care of a

patient who already has it and

how to prevent at-risk patients
from developing it.
But first, lets review the
pathophysiology of DVT.

Youre so vein
The veins of the body consist of
the superficial veins that run
near the surface of the skin, and
the deep veins, such as the great
saphenous and popliteal veins,
that are located underneath the
muscles and run parallel to the

March/April 2008 Nursing made Incredibly Easy! 29

Lower limb veins

Vena cava
Common iliac vein
Internal iliac vein
External iliac vein

Great saphenous vein

Femoral vein
Deep veins of the knee

Superficial veins of the knee

Popliteal vein
Small saphenous vein
Fibular vein

Posterior tibial vein

Great saphenous vein
Deep veins of the foot

Superficial veins of the foot

arteries (see Lower limb veins). Smaller veins

connect the superficial and deep veins and
help move blood from the skin to the deep
veins. Blood is then moved back to the
heart with the aid of valves in the superficial and deep veins that allow unidirectional flow. Various factors influence blood
flow through the legs: Valves in the veins
prevent backflow, while walking and muscle movement in the legs aid blood flow
back to the heart. Since blood flow is already slowed as its squeezed from the connecting veins into the deep veins, theres a
high risk of clot (thrombus) formation if
any further slowing of the flow occurs. Any
time blood slows or is stationary, as in
standing or sitting for long periods, theres
the potential for a thrombus to form.
Lets now take a look at blood flow to better understand thrombus formation.

Dont slow the flow!

Anything that alters the strength of the
blood vessel wall can slow blood flow and
cause DVT. Think of the vascular system as
an intertwining water hose. Normally, water flows through the hose without any difficulty but if you kink the hose, you reduce
the flow of water. Over time, dirt and other
impurities build up within the hose and
add to the reduced flow. The same principles apply to the vascular system. So every
time you sit down, curl your legs, or cross
your arms, you reduce blood flow, which
can cause small clots to form. Normally, the
body immediately breaks down these clots.
However, when stasis of blood (venous stasis), vessel wall injury, and hypercoagulabilitythe three factors known as Virchows
triadare present, an abnormal thrombus
will most likely form (see A closer look at
Virchows triad).
How does the thrombus form? Lets take a
look at that next.

A thrombus among us
Mechanical or physiologic damage to the
vessel wall leads to platelet activation. Ex30 Nursing made Incredibly Easy! March/April 2008

amples of mechanical damage include high

velocity trauma in which bones are broken
and surgery, especially orthopedic or abdominal surgery. Examples of physiologic
damage include hypertension, in which the
vessel wall weakens over time, and phlebitis, in which a vein is inflamed. The platelets adhere to one another and clump together, forming a thrombus (see Picturing
venous thrombosis). After a thrombus forms,
it flows in the body and is either dissolved
over time or grows and becomes large
enough to occlude a vessel. If the thrombus
occludes a vessel, its known as an embolus.
After an embolus forms, the blood behind
the blockage slows and the veins expand to
accommodate an increase in volume. This
leads to a general pooling of blood that
slows the blood further and causes more
clots to form. Ultimately, the drainage of the
lymphatic system slows, leading to edema of
the affected extremity.
So whos at risk for developing DVT?
Thats up next.

Risks, risks everywhere

Patients who are most at risk for DVT are
those undergoing major surgery, especially
orthopedic surgery. Other at-risk patients
include those who smoke or have lung disease, diabetes, blood disorders, and periph-

Picturing venous thrombosis

Tunica intima
Tunica media
Tunica adventitia
Thrombus
Valve
Endothelium
Internal elastic
membrane
Smooth muscle
External elastic
membrane

eral vascular disease. But remember, any

hospitalized patient is at risk for DVT, especially those wholl be immobile for an extended period of time or are of advancing
age. If your patient has any one of the three
factors in Virchows triad, theres the potential for DVT.
See Which surgical patients are at risk for
DVT? for more information.

A closer look at Virchows triad

Risk factors

Common causes

Changes in blood flow

Stasis related to prolonged immobility, paralysis, varicose veins,

or heart failure
Increased blood viscosity

Changes in the vessel wall

Atherosclerosis leading to rupture of plaque on the vessel wall

exposes thrombogenic material, activating platelets and the
coagulation cascade

Changes in blood coagulability

Traumatic, burn, and surgical injuries because of tissue damage,

release of tissue factors, and activation of the extrinsic pathway
of coagulation
Cancer (fibrinolytic activity may be reduced and malignant tissue
may promote coagulation)

March/April 2008 Nursing made Incredibly Easy! 31

Hes really a
superficial vein. He
just thinks if he
reads enough
literature, people
will start to think
hes deep.

Its a sign
How do you know if your patient has
DVT? And if he does, is he at risk for more
complications? Lets now review signs and
symptoms to be alert for and then well
take a look at potential complications.
DVT may be difficult to recognize immediately because many patients dont exhibit
signs and symptoms or their symptoms
are nonspecific. Signs and symptoms
include:
edema or swelling of the affected extremity
redness
pain or tenderness
an increase in the temperature of the
affected extremity compared with the
rest of the body
cyanosis and mottling of the skin due
to stagnant blood flow.
Although Homans sign (pain with dorsiflexion of the foot) has historically been used
to assess DVT, its not a reliable or valid sign;
in fact, the literature suggests that up to 50%
of patients with DVT dont have a positive
Homans sign.

lodged thrombus obstructs the pulmonary

artery bed (see Picturing pulmonary emboli).
PE can be life-threatening and may require
mechanical ventilation. If your patient complains of any of these signs and symptoms,
notify the health care provider immediately:
severe dyspnea
tachypnea
chest pain
cough
hemoptysis (coughing up blood).
Another complication occurring in 40% to
60% of patients with DVT is postthrombotic
syndrome. Caused by a combination of factors, such as back flow of blood related to
faulty valves and blockage that remains in
the vessel, signs and symptoms of this syndrome include pain, increased swelling, skin
ulcers, and hyperpigmentation. How long
postthrombotic syndrome persists depends
on the patients ability to form collateral circulation around any remaining embolus.
Treatment for this condition is palliative,
including anticoagulation therapy and elevating the affected extremity to help decrease swelling and pain.

It can get complicated

Assessment = early detection

The most serious complication of DVT is

pulmonary embolism (PE), in which the dis-

Lets say youre worried that your overweight patient with diabetes who doesnt
want to get out of
his bed to ambulate
Which surgical patients are at risk
is developing DVT.
for DVT?
What do you do?
Careful assessment
Risk level
Patient population
will help detect
Patients undergoing hip or knee surgery
Highest
early signs of a ve Patients with multiple risk factors undergoing surgery
nous disorder of the
Patients with major trauma
legs. Assess for:
High
Patients greater than age 60 undergoing surgery
limb pain
Patients age 40 to 60 with additional risk factors
a feeling of heaviundergoing surgery
ness
Patients with additional risk factors undergoing minor
Moderate
functional imsurgery
Patients age 40 to 60 with no additional risk factors
pairment
undergoing surgery
ankle engorgeLow
Patients less than age 40 with no additional risk factors
ment
undergoing minor surgery
edema
differences in leg

32 Nursing made Incredibly Easy! March/April 2008

I spy a thrombus. We
better head for shore.

circumferences bilaterally from thigh to

ankle
an increase in the surface temperature of
the leg, particularly the calf or ankle
areas of tenderness or superficial thrombosis.
One of the most reliable physical indications of DVT is unilateral edema of the
extremity. Measure the extremity and compare your findings with baseline measurements to detect an increase in circumference. Changes should be reported and documented.

Diagnosis: DVT
Because DVT is often difficult to detect clinically, diagnostic studies may be indicated.
If the health care provider suspects DVT, he
may order a venous ultrasound of the patients legs, magnetic resonance imaging

(MRI), a venogram, or a Ddimer test.

Lets take a closer look at
these tests.
Duplex venous ultrasonography, which may be
performed at the bedside, is
one of the simplest diagnostic tests for DVT. Ultrasound
imagery can reveal a thrombus in a deep vein; the
Doppler ultrasound measures the blood flow velocity
in veins and can detect flow abnormalities.
Although a duplex study is noninvasive and
relatively simple to perform, its accuracy
depends on the technicians skill. If the ultrasound is negative for DVT and the health
care team still suspects that the patient has
DVT, a venogram may be indicated to make

Picturing pulmonary emboli

Infarcted area

Multiple emboli in
small branches of
left pulmonary artery

Large, solid embolus

March/April 2008 Nursing made Incredibly Easy! 33

The superficial
veins connected to
the perforator vein,
the perforator
veins connected to
the deep vein...I love
this song!

a definitive diagnosis.
MRI is another noninvasive study
that can be used to detect DVT in the
proximal deep veins. Whether to use
this test or a venogram depends on the
patients clinical findings; MRI is more
useful than venography in patients with suspected DVT of the inferior vena cava or
pelvic veins.
Although its being replaced by ultrasound, the venogram is still considered by
many health care providers to be the gold
standard for diagnosing DVT. During this
invasive test, the patient is placed on a
fluoroscopic table thats usually tilted 45
degrees, and a contrast medium is injected
into a superficial foot vein. A clinician
observes the flow of contrast medium by

cheat
Superficial veins lie
just beneath the
skin; they drain
through perforator
veins into deep
veins.

Perforator veins
Perforator veins
connect superficial
to deep veins.

Deep veins
Deep veins receive
venous blood from
perforator veins and
return it to the heart.

34 Nursing made Incredibly Easy! March/April 2008

sheet

Superficial veins

fluoroscopy and takes X-rays; if the contrast medium doesnt fill the veins normally, acute DVT is confirmed. Complications
of venography include hypersensitivity
reactions to the contrast medium, acute
renal failure because of the volume of contrast medium used, and extravasation of
the contrast medium (especially in patients
with a history of arterial insufficiency
because of tissue necrosis and ulceration).
The risk of acute renal failure is higher in
elderly patients and in patients with diabetes, hyperuricemia, or multiple myeloma.
A D-dimer test is a blood test to measure
fibrin degradation fragments generated by
fibrinolysis. An elevated D-dimer level indicates a thrombotic process but isnt specific
to DVT. This test is useful as an adjunct to
noninvasive testing. If the patient has a low
clinical probability of DVT and a negative Ddimer test, DVT can be ruled out without an
ultrasound.
It turns out your suspicions were correctyour patient has DVT. Whats the next
step? Lets look at treatment options next.

Anticoagulation is A-OK
The treatment goals for DVT are to prevent the thrombus from growing and fragmenting, which increases the risk of PE; to
prevent recurring thrombi; and to let the
bodys own fibrinolytic system work. Anticoagulant therapy, with unfractionated
heparin, low-molecular-weight heparin
(LMWH), or oral anticoagulants such as
warfarin (Coumadin), is the first-line treatment. Thrombolytic therapy or the factor
XA inhibitor fondaparinux (Arixtra) may
also be used. Depending on the patients
risk factors, anticoagulant therapy may
last from 6 months to 1 year if he has idiopathic DVT or indefinitely if he continues
to have recurring thrombi. Lets take a
closer look.
Unfractionated heparin is administered
by intravenous (I.V.) infusion for 5 to 7
days to prevent the growth of a thrombus

and the development of new thrombi. An

electronic infusion device is used to prevent the inadvertent infusion of large volumes, which can cause hemorrhage.
Unfractionated heparin can also be given
subcutaneously to prevent the development of DVT. The dosage of unfractionated
heparin depends on the patients activated
partial thromboplastin time, international
normalized ratio (INR), and platelet count.
Heparin is at an effective (therapeutic) level
when the patients partial thromboplastin
time is 1.5 times normal. Patients receiving
unfractionated heparin for a long period of
time (several days to weeks) are at risk for
a sudden decrease in platelet count (30%)
known as heparin-induced thrombocytopenia (HIT). If HIT develops, heparin must be
discontinued.
Associated with fewer bleeding complications and a lower risk of HIT than unfractionated heparin, LMWH, such as enoxaparin (Lovenox), may be used instead to
prevent thrombus growth and new thrombi
formation. Given in one or two subcutaneous injections per day, doses are adjusted
according to the patients weight and are
based on the specific product and facility
protocol. LMWH is more expensive than
unfractionated heparin, but it can be used
safely in pregnant women and patients who
take it may be more mobile.
An oral anticoagulant, such as warfarin
(a vitamin K antagonist), is typically administered with heparin therapy. Once the therapeutic level is reached, heparin can be discontinued. If the patient requires long-term
therapy, warfarin is frequently used. The
dosage of warfarin depends on the patients
prothrombin time and INR; the therapeutic
level is reached when the patients prothrombin time is 1.5 to 2 times normal or
the INR is 2 to 3. For more information on
warfarin, prothrombin time, and INR, see
Going with the flow: Warfarin from our
July/ August 2004 issue and Is this on the
level? from our July/August 2006 issue.
Thrombolytic therapy dissolves thrombi

When anticoagulant
therapy is a no-no
Anticoagulant therapy is contraindicated if your
patient has:
bleeding from the gastrointestinal, genitourinary, respiratory, or reproductive systems
hemorrhagic blood dyscrasias
an aneurysm
severe trauma
alcoholism
recent or impending surgery of the eye,
spinal cord, or brain
severe liver or kidney disease
recent cerebrovascular hemorrhage
an infection
an open ulcerative wound
an occupation that involves a significant risk
for injury
recently delivered a baby.

Surgery
may be
a last
resort.

in 50% of patients. A thrombolytic, such as

activase (Alteplase) or reteplase (Retavase),
is given within the first 3 days after acute
thrombosis. Thrombolytics cause less longterm damage to the venous valves and
reduce the incidence of postthrombotic syndrome; however, they have a higher risk of
bleeding than heparin. If bleeding cant be
stopped, thrombolytic therapy must be discontinued.
Unlike LMWH, which acts on thrombin
and factor Xa, fondaparinux only inhibits
factor Xa. Because it doesnt affect platelets,
fondaparinux doesnt cause HIT. Fondaparinux is given subcutaneously at a fixed dose
once a day and is excreted unchanged by the
kidneys; therefore, it must be used with caution in patients with renal insufficiency and
its contraindicated in patients with renal
failure.
Surgery may be necessary if anticoagulant
or thrombolytic therapy is contraindicated,
the patient is at high risk for PE, or his
venous drainage is so compromised that permanent damage is likely (see When anticoagulant therapy is a no-no). Thrombectomy, or
removal of the thrombus, is the procedure of
March/April 2008 Nursing made Incredibly Easy! 35

Warfarin to the
rescuethats
Mr. Super
Warfarin to
you!
choice under these circumstances. During
this procedure, a catheter is used to deliver a
thrombolytic directly into the clot to dissolve
it. A vena cava filter may also be placed
through the catheter into the
groin, just below the junction
of the inferior vena cava and
the lowest renal veins, to trap large
emboli and prevent PE. About the
size of a quarter, this filter made of
wire mesh catches any clots that
break off the DVT and head for the
lungs via the inferior vena cava. A
vena cava filter for short-term use has
recently been introduced, designed to be
removed once the increased risk of PE
subsides.
So what can you do to help your patient
whos receiving anticoagulant therapy?
Lets delve into the care of a patient with
DVT next.

Take care

What affects
Increased
anticoagulation
Angelica
Celery
Chamomile
Cinchona
Garlic
Ginger
Ginkgo biloba
Grapefruit juice
Horse chestnut
Licorice
Quinine
Sweet clover

When caring for a patient with DVT, you

must:
monitor for potential complications,
such as bleeding or HIT. Spontaneous
bleeding anywhere in your patients body
is the most common complication of anticoagulant therapy. Bleeding from the kidneys, bruises, nosebleeds, and bleeding
gums are early
signs of excessive
warfarin?
heparin dosage. To
immediately reDecreased
anticoagulation
verse the effects of
Broccoli
heparin, the health
Cabbage
care provider may
Collard leaves
order I.V. prota Ginseng
mine sulfate. Prota Lettuce
mine sulfate is
Spinach
most effective in re Stinging nettle
versing the effects
Turnip leaves
of unfractionated
heparin, but it may
also be used in patients receiving
LMWH. If your pa-

36 Nursing made Incredibly Easy! March/April 2008

tient receiving warfarin experiences bleeding, the health care provider may order
oral or low-dose I.V. vitamin K or an infusion of fresh frozen plasma or prothrombin concentrate. HIT is another
complication you must watch out for.
Early signs and symptoms of HIT include
a decreasing platelet count, the need for
increasing doses of heparin to maintain
the therapeutic level, and hemorrhagic
complications (skin necrosis at the injection site or sites distal to the thrombus,
skin discoloration, hematomas, purpura,
and blistering). If your patient develops
HIT, the health care provider may order a
direct thrombin inhibitor, such as I.V. lepirudin (Refludan) or argatroban.
monitor for drug interactions. If your patient is taking an oral anticoagulant, you
must monitor his medication schedule because many medications and supplements
accelerate or inhibit the effects of warfarin
(see What affects warfarin?).
provide pain relief. Depending on the
extent and location of the thrombus, your
patient may be on bed rest for 5 to 7 days.
To promote circulation and increase comfort, periodically elevate his feet and lower
legs above his heart. Help him perform active and passive leg exercises, particularly
with the calf muscles, to increase venous
flow. Apply warm, moist packs to the affected leg, as ordered, to reduce the discomfort of the thrombus. An analgesic
may also be ordered to control pain.
encourage early ambulation. Once hes
ambulatory, instruct your patient to avoid
sitting for more than 2 hours at a time. He
should walk at least 10 minutes every 1 to 2
hours if possible to help prevent venous
stasis.
perform discharge teaching. Educate
your patient about the signs and symptoms of DVT to report, such as new
swelling or increased swelling of the affected limb, skin breakdown, pain, and
weak or absent pulses. Also teach him
the signs and symptoms of PE, such as

With treatment, your

patients blood will
flow as free as me in
the sea!

shortness of breath,
did you
chest pain, blue
know?
nail beds, and
Want to beef up
tachypnea. Instruct
your practice when
him to go to the
it comes to DVT
emergency departprevention? Check
ment immediately
out the American
if he experiences
Association of
any of these sympCritical-Care
toms. Inform your
Nurses Practice
patient about the
Alert for Deep Vein
Thrombosis
risk of bleeding asPrevention at
sociated with antihttp://www.aacn.
coagulant therapy
Have him demonstrate the technique
org/AACN/practice
and the signs and
back to you. Let him know that its comAlert.nsf/Files/dvt/
symptoms to be
mon to experience some bruising around
$file/DVT%20
alert for, such as
the injection sites but to contact his health
Prevention%2012changes in mental
care provider if the bruises begin to
2005.pdf.
status, a racing
spread. Finally, assist your patient with
pulse, and exsetting up follow-up appointments, which
tremely pale skin (see Patient teaching for
may include a computed axial tomograanticoagulants). If your patient is going
phy scan of his chest to check for PE and
home on warfarin, tell him to avoid foods magnetic resonance venography or a vehigh in vitamin K, such as avocados,
nous Doppler scan to monitor the status
broccoli, brussel sprouts, cabbage, green
of the thrombus.
onions, liver, and green leafy vegetables.
But how about steps you can take to preAnd make sure he understands that hell
vent your at-risk patients from developing
need regular blood draws to monitor his
DVT? Lets take a minute to review prevenprothrombin time and INR. If hes going
tion strategies.
home on unfractionated heparin,
Patient teaching for anticoagulants
hell need his parTeach your patient who has been prescribed an anticoagulant the following:
tial prothrombin
Take the anticoagulant at the same time each day, usually between 8 a.m. and 9 a.m.
time monitored on
Because other medications affect the action of anticoagulants, dont take vitamins, cold medicines,
a monthly basis as
antibiotics, aspirin, mineral oil, or anti-inflammatory drugs without consulting your health care prowell. If your pavider.
tient is going home
Avoid alcohol because it may change your bodys response to the anticoagulant.
on LMWH or fon Avoid food fads, crash diets, or marked changes in eating habits.
daparinux, teach
Avoid injury that can cause bleeding.
If you experience faintness, dizziness, increased weakness, severe headaches or abdominal pain,
him the proper
reddish or brown urine, red or black stool, any unusual bleeding, nosebleeds, bruises that enlarge, or
technique for subrash, contact your health care provider immediately.
cutaneous injec Contact your health care provider before having dental work or elective surgery and inform the dentions into the abtist or surgeon that youre taking an anticoagulant.
domen (2 inches
For women, contact your health care provider if you suspect youre pregnant.
from the umbili Wear or carry identification indicating the anticoagulant youre taking.
cus) and make sure
Keep all appointments for blood tests.
he knows to rotate
the injection sites.
March/April 2008 Nursing made Incredibly Easy! 37

Your role in prevention

Elastic compression stockings, which exert
sustained, evenly distributed pressure
over the calves to help increase blood flow
in the deep veins, are usually ordered for
patients with venous insufficiency to prevent DVT. They may be knee-high, thighhigh, or like pantyhose. The health care
provider may order short-stretch elastic
wraps instead, which are applied from the
toes to the knee in an overlapping spiral
pattern using a one- or two-layer system.
Intermittent pneumatic compression devices may also be used with elastic compression stockings to prevent DVT. These
devices consist of plastic knee- or thighhigh leg sleeves attached to air hoses and
an electric controller. The leg sleeves fill
with air to apply pressure to the ankle,
calf, and thigh.
If your patient is receiving compression
therapy, inspect his skin for signs of irritation and his calves for tenderness whenever
you remove the stockings or wraps. Report

any skin changes or tenderness to the health

care provider immediately.

The moral of the story:

Prevention
DVT is a serious, but preventable, condition. With diligent care, your patient with
DVT will not only recover, but avoid recurrence as well. And with an eye on prevention, your at-risk patients will be less likely
to develop DVT. Now thats good news!

Learn more about it

Day MW. Recognizing and managing deep vein thrombosis. Nursing2003. 33(5):36-42, May 2003.
Pathophysiology Made Incredibly Visual! Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2008:66-67.
Smeltzer SC, et al. Brunner and Suddarths Textbook of
Medical-Surgical Nursing, 11th edition. Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2007:1004-1010.
Surgical Care Made Incredibly Visual! Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2007:185.
Turka J. Is this on the level? Nursing Made Incredibly Easy!
4(4):7-9, July/August 2006.
Wound Care Made Incredibly Visual! Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2008:107.
Zajac PM. Going with the flow: Warfarin. Nursing Made
Incredibly Easy! 2(4):52-57, July/August 2004.

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In too deep: Understanding deep vein thrombosis

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ANCC/AACN CONTACT HOURS

In too deep: Understanding deep vein thrombosis

GENERAL PURPOSE: To provide the professional nurse with an overview of the pathophysiology, treatment, and prevention of deep
vein thrombosis (DVT). LEARNING OBJECTIVES: After reading this article and taking this test, you should be able to: 1. Discuss the
pathophysiology, risk factors, and symptoms associated with DVT. 2. List diagnostic tests and treatment options for DVT. 3. Identify
nursing interventions for care of the patient with DVT and its complications.
1. Which of the following is a component of Virchows
triad?
a. increased blood flow
b. venous stasis
c. decreased coagulability
2. A clot that occludes a vessel is called
a. an embolus.
b. a thrombus.
c. postthrombotic syndrome.
3. Which of the following patients is at highest risk for
DVT?
a. a nonsmoker undergoing outpatient arthroscopy
b. a smoker undergoing knee replacement
c. a smoker whos ambulatory following appendectomy
4. The most reliable physical sign of DVT is
a. unilateral pain.
b. positive Homans sign.
c. unilateral edema.
5. Which symptoms are commonly associated with
pulmonary embolism (PE)?
a. dyspnea and cough
b. edema and chest pain
c. tachycardia and hyperpigmentation
6. Which noninvasive test is useful in diagnosing DVT of
the inferior vena cava?
a. venogram
b. Doppler ultrasound
c. magnetic resonance imaging
7. Which statement about the D-dimer test is correct?
a. The D-dimer level is checked only after ultrasound confirmation of DVT.
b. A negative D-dimer and low clinical probability rule out
DVT.
c. An elevated D-dimer level is only seen with DVT.
8. A therapeutic partial thromboplastin time (PTT) should
be
a. 3 times normal.
b. 2 times normal.
c. 1.5 times normal.
9. Heparin-induced thrombocytopenia (HIT) isnt a concern
when the patient is anticoagulated using
a. unfractionated heparin.
b. enoxaparin.
c. fondaparinux.

b. Patients receiving enoxaparin must be on bed rest.

c. Enoxaparin is safe for pregnant women.
11. Thrombectomy is most likely to be performed on the
patient who
a. has hemorrhagic blood dyscrasias.
b. has a normal D-dimer and low risk for PE.
c. has an international normalized ratio of 2.5 on heparin
therapy.
12. Which statement about vena cava filter placement is
correct?
a. Its placed by a catheter inserted into the subclavian vein.
b. Its a device placed in the inferior vena cava above the
renal veins.
c. Its purpose is to trap emboli headed for the lungs.
13. The most common complication of anticoagulant
therapy is
a. drug interactions.
b. spontaneous bleeding.
c. renal failure.
14. Which of the following can be used to reverse the
effects of heparin?
a. I.V. protamine sulfate
b. I.V. vitamin K
c. fresh frozen plasma
15. Which isnt a sign of HIT?
a. a 30% drop in platelet count
b. the need for smaller doses of heparin to maintain a therapeutic PTT
c. hematomas and blistering
16. To prevent venous stasis, you instruct your patient to
ambulate for 10 minutes
a. once a day.
b. every 8 hours.
c. every 1 to 2 hours.
17. Which food should the patient on warfarin avoid?
a. broccoli
b. milk
c. red meat
18. Explain to your patient that wearing compression
stockings after discharge will help by
a. slowing bleeding from superficial veins.
b. increasing blood flow in deep veins.
c. mobilizing residual clots in the legs.

10. Which statement about the use of enoxaparin is

correct?
a. Enoxaparin is associated with a higher risk of bleeding than
unfractionated heparin.

Turn to page 54 for the CE Enrollment Form.

March/April 2008 Nursing made Incredibly Easy! 39