A nurse is caring for a client who has a thrombus and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot.
Which of the following responses should the nurse make?
"The time it takes for heparin to dissolve a clot depends on the size of the clot.".
"The time it takes for heparin to dissolve a clot varies between clients.".
"Usually, it takes at least 2 to 3 days for heparin to dissolve a clot.".
"Heparin prevents new clots from forming rather than dissolving existing ones.".
The Correct Answer is D
Heparin is an anticoagulant that is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels 1.
However, heparin will not dissolve blood clots that have already formed, but it may prevent the clots from becoming larger and causing more serious problems 12.
Choices A, B, and C are incorrect because heparin does not dissolve existing clots. Instead, it works to prevent new clots from forming 12.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should set the flow rate to deliver 40 gtts/min.
This can be calculated by multiplying the infusion rate (120 mL/hr) by the drop factor (60 gtt/mL) and then dividing by the number of minutes in an hour (60 min/hr): (120 mL/hr) * (60 gtt/mL) / (60 min/hr) = 120 gtt/hr / 60 min/hr = 2 gtt/min.
Choice A is not the best answer because setting the flow rate to deliver 20 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice B is not the best answer because setting the flow rate to deliver 30 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice D is not the best answer because setting the flow rate to deliver 50 gtts/min would provide a higher infusion rate than desired.
Correct Answer is A
Explanation
The nurse should inform the charge nurse about her suspicion.
The charge nurse is responsible for managing the unit and can take appropriate action to investigate the matter and ensure that proper procedures are followed.
Choice B is incorrect because reporting the incident to the hospital security department is not the first step that should be taken.
The charge nurse should be informed first and can then decide if further action, such as involving the security department, is necessary.
Choice C is incorrect because it is not appropriate for the nurse to ask assistant personnel (AP) to observe the other nurse’s actions.
This could create a hostile work environment and may not be an effective way to address the issue.
Choice D is incorrect because approaching the other nurse directly to discuss the suspicion may not be the best course of action.
It could create tension and conflict between the two nurses and may not lead to a resolution of the issue.
Instead, informing the charge nurse allows for proper procedures to be followed in addressing the matter.
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