A nurse is caring for a client who has a deep vein thrombosis, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?
"Heparin enhances the effects of the warfarin."
"Both heparin and warfarin work together to dissolve the clots."
"Heparin will be continued until the warfarin reaches a therapeutic level!"
"I will ask the charge nurse to call your provider and get an explanation"
The Correct Answer is C
A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.
B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.
C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.
D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Take the medication on an empty stomach":
Taking baclofen with food can help reduce gastrointestinal side effects such as nausea. However, the instruction to take it on an empty stomach is not necessary or typically recommended. Ensuring consistent timing with or without food is more practical for adherence and reducing potential side effects.
B) "Stop taking the medication immediately for headache":
While headaches can be a side effect of baclofen, stopping the medication abruptly can lead to withdrawal symptoms or worsening of muscle spasticity. It's important to discuss any persistent or severe headaches with the healthcare provider to determine the appropriate management.
C) "Diarrhea is an adverse effect of this medication":
Diarrhea can indeed be a side effect of baclofen, but it is not one of the primary or most common side effects. Constipation is actually more frequently observed. Monitoring for gastrointestinal changes and discussing them with the healthcare provider is important for appropriate management.
D) "Avoid driving until the medication's effects are evident":
This instruction is crucial because baclofen can cause drowsiness or dizziness, especially when starting the medication or when the dosage is adjusted. It is important for the client to avoid activities such as driving until they are aware of how the medication affects them to ensure safety.
Correct Answer is D
Explanation
A) Notify the nurse manager:
While it's important to communicate the error to the nurse manager and appropriate supervisors, the immediate priority is to address the client's current condition and ensure their safety.
B) Complete an incident report:
Filling out an incident report is necessary to document the error and ensure proper follow-up and investigation. However, the client's immediate well-being takes precedence.
C) Give the client 15 to 20 g of carbohydrate:
Administering carbohydrates may be necessary if the client is hypoglycemic, but checking the blood glucose level first is essential to confirm the current status and determine the appropriate intervention.
D) Check the client's blood glucose level:
This is the priority action because it allows the nurse to assess the client's current blood glucose level and determine if corrective action, such as administering carbohydrates or further insulin adjustments, is needed to address any potential hypoglycemia resulting from the incorrect insulin dose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
