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 B
Explanation
The nurse should monitor the client for fever as an indication that the client is experiencing an acute infusion reaction to IV amphotericin
Fever is a common symptom of an infusion reaction to amphotericin
Choice A is wrong because pedal edema is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice C is wrong because hyperglycemia is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice D is wrong because dry cough is not a commonly reported symptom of an acute infusion reaction to amphotericin
Correct Answer is B
Explanation
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes of exposure to an allergen, such as penicillin.
One of the symptoms of anaphylaxis is wheezing, which is caused by the constriction of the airways and a swollen tongue or throat.
Choice A is wrong because hypertonia (increased muscle tone) is not a known symptom of anaphylaxis.
Choice C is wrong because urinary retention (inability to completely empty the bladder) is not a known symptom of anaphylaxis.
Choice D is wrong because increased blood pressure is not a known symptom of anaphylaxis; in fact, anaphylaxis can cause a sudden drop in blood pressure.
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