A nurse is assessing a client who is receiving heparin therapy for deep-vein thrombosis.
Which of the following findings should indicate to the nurse that the therapy is effective?
Platelets within the expected reference range.
Decreased INR.
Presence of pedal pulses bilaterally.
Reduced calf circumference.
The Correct Answer is D
Heparin therapy is used to prevent thrombus propagation and distal embolization while allowing the endogenous fibrinolytic system to dissolve existing clots in deep-vein thrombosis (DVT)1.
A reduction in calf circumference may indicate that the clot is dissolving and the therapy is effective.
Choice A is wrong because platelets within the expected reference range do not necessarily indicate that heparin therapy for DVT is effective.
Choice B is wrong because INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin therapy.
Choice C is wrong because the presence of pedal pulses bilaterally does not necessarily indicate that heparin therapy for DVT is effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Total parenteral nutrition (TPN) is a method of administration of essential nutrients to the body through a central vein.
TPN solutions are customized for each client’s needs, including the exact amount of calories and nutrients necessary for total nutritional needs.
Monitoring the client’s weight daily is important to determine if nutritional goals are being met and to assess fluid volume status.
Choice B is wrong because TPN solutions are concentrated and can cause thrombosis of peripheral veins, so they require a central venous catheter and should not be hung to gravity to infuse.
Choice C is wrong because TPN solution should not be titrated to blood pressure.
Choice D is wrong because the client’s blood glucose level should be monitored more frequently than weekly when receiving TPN.
Correct Answer is A
Explanation
Spironolactone is a potassium-sparing diuretic that can increase potassium levels in the blood.
It is important for clients taking spironolactone to limit their intake of potassium-rich foods to prevent hyperkalemia (high potassium levels).
Choice B is wrong because “I will take the medication on an empty stomach,” is not the correct answer because spironolactone can be taken with or without food.
Choice C is wrong because “I will use salt substitutes in place of table salt,” is not the correct answer because many salt substitutes contain potassium and can increase the risk of hyperkalemia.
Choice D is wrong because “I will double up on my medication if I miss a dose,” is not the correct answer because it is not recommended to double up on medication if a dose is missed.
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