Question 1

A patient who has atrial fibrillation (AF)has been taking warfarin (Coumadin).The primary care nurse practitioner (NP)plans to change the patient's medication to dabigatran (Pradaxa).To do this safely,the NP should:

A) initiate dabigatran when the patient's international normalized ratio (INR) is less than 2.
B) start dabigatran 7 to 14 days after discontinuing warfarin.
C) begin giving dabigatran 1 week before discontinuing warfarin.
D) order frequent monitoring of the patient's INR after dabigatran therapy begins.

Accepted Answer

There are no requirements for monitoring the INR or other measures for patients taking dabigatran.When changing from warfarin,it is recommended that dabigatran be initiated when the INR is less than 2.

Question 2

A patient in the clinic develops sudden shortness of breath and tachycardia.The primary care NP notes thready pulses,poor peripheral perfusion,and a decreased level of consciousness.The NP activates the emergency medical system and should anticipate that this patient will receive:

A) intravenous alteplase.
B) low-dose aspirin and warfarin.
C) low-molecular-weight heparin (LMWH).
D) unfractionated heparin (UFH) and warfarin.

Accepted Answer

This patient has unstable pulmonary embolism (PE)and should receive thrombolytic therapy.Intravenous alteplase is the preferred agent.UFH and warfarin are recommended for stable PE.LMWH is beneficial in submassive PE and deep vein thrombosis (DVT)but is controversial for treatment of massive PE.

Question 3

A patient who has had a new onset of AF the day prior will undergo cardioversion that day.The primary care NP will expect the cardiologist to:&#10;A) give clopidogrel after administering cardioversion.&#10;B) administer cardioversion without using anticoagulants.&#10;C) give warfarin and aspirin before attempting cardioversion.&#10;D) give low-dose aspirin before administering cardioversion.

Accepted Answer

If the onset of AF has occurred within 48 hours,cardioversion can be done without anticoagulation.Clopidogrel is used in other cases for patients who cannot take aspirin.For patients with rheumatic mitral valve disease and AF or a history of systemic embolism,cardioversion plus aspirin is used.Warfarin is used in patients with one or more risk factors for stroke.

Question 4

A patient who has disabling intermittent claudication is not a candidate for surgery.Which of the following medications should the primary care NP prescribe to treat this patient?&#10;A) Cilostazol (Pletal)&#10;B) Warfarin (Coumadin)&#10;C) Pentoxifylline (Trental)&#10;D) Low-dose, short-term aspirin

Accepted Answer

Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline.Warfarin is not indicated.Patients with chronic limb ischemia are treated with lifelong aspirin therapy.

Question 5

A patient comes to the clinic with a complaint of gradual onset of left-sided weakness.The primary care NP notes slurring of the patient's speech.A family member accompanying the patient tells the NP that these symptoms began 4 or 5 hours ago.The NP will activate the emergency medical system and expect to administer:

A) 325 mg of chewable aspirin.
B) LMWH.
C) intravenous alteplase and aspirin.
D) warfarin (Coumadin) and aspirin.

Accepted Answer

Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred 3 hours previously.The administration of anticoagulation or antiplatelet agents during the first 24 hours is not recommended.The oral administration of aspirin within 24 to 48 hours after stroke onset is recommended.

Question 6

A patient who is obese is preparing to have surgery.To help prevent venous thromboembolism (VTE),the primary care NP should prescribe:&#10;A) low-dose aspirin once daily.&#10;B) clopidogrel (Plavix) 75 mg once daily.&#10;C) enoxaparin (Lovenox) 30 mg twice daily.&#10;D) warfarin (Coumadin) titrated to achieve an INR of 3.5.

Accepted Answer

The American College of Clinical Pharmacy recommends against the use of aspirin alone for prophylaxis of VTE.Patients undergoing surgery who are at moderate to high risk for VTE should receive unfractionated heparin or low-molecular-weight heparin,such as enoxaparin.Aspirin may be part of the prophylaxis regimen.Clopidogrel and warfarin are not recommended.

Question 7

A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant.The NP should expect that this patient will use which of the following anticoagulant medications?&#10;A) Aspirin&#10;B) Heparin&#10;C) Dabigatran&#10;D) Warfarin

Accepted Answer

Heparin does not cross the placental barrier and is the drug of choice for anticoagulation therapy during pregnancy,despite its category C classification.Aspirin is not recommended during the last 3 months of pregnancy.Dabigatran is not recommended.Warfarin crosses the placental barrier.

Question 8

A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled.The primary care NP should counsel this patient to:

A) avoid foods that are high in vitamin K for several days.
B) take a double dose of the medication the next morning.
C) refill the prescription and take today's dose immediately.
D) skip today's dose and resume a regular dosing schedule in the morning.

Accepted Answer

Consistency is the key to successful warfarin treatment,and the patient should take the medication at the same time every day.For missed doses,the patient should take the medication as soon as possible after the missed dose or not at all that day.Because it is late afternoon,the patient should skip the dose and resume normal scheduling the next day.It is not necessary to avoid foods high in vitamin K.Patients should not double up the next day.

Question 9

A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively.The NP should tell the patient that it will be necessary to take:

A) daily low-dose aspirin for 1 year.
B) heparin injections as needed based on activated partial thromboplastin time levels.
C) lifelong warfarin combined with enoxaparin as needed.
D) warfarin for 3 months postoperatively plus long-term aspirin.

Accepted Answer

Patients with biosynthetic valves should receive anticoagulation for 3 months with long-term aspirin prophylaxis.Patients with biosynthetic valves should receive anticoagulation for 3 months (INR goal,2 to 3).Long-term prophylaxis for these patients should include aminosalicylic acid (75 to 100 mg daily),unless AF is present.

Question 10

An 80-year-old patient who has persistent AF takes warfarin (Coumadin)for anticoagulation therapy.The patient has an INR of 3.5.The primary care NP should consider:&#10;A) lowering the dose of warfarin.&#10;B) rechecking the INR in 1 week.&#10;C) omitting a dose and resuming at a lower dose.&#10;D) omitting a dose and administering 1 mg of vitamin K.

Accepted Answer

This patient's INR is only minimally prolonged,so no dose reduction is required.The NP should recheck the INR periodically.If the INR becomes more prolonged,lowering the dose of warfarin is recommended.If the INR approaches 5,omitting a dose and resuming at a lower dose is recommended.Vitamin K is used for an INR of 9 or greater.

Deck 25: Agents that Act on Blood