A nurse is caring for a client who has deep vein thrombosis (DVT). The client has received intravenous (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?
"Both heparin and warfarin work together to dissolve the clots."
"Heparin enhances the effects of the warfarin."
"I will ask the charge nurse to call your provider and get an explanation."
"Heparin will be continued until the warfarin reaches a therapeutic level."
The Correct Answer is D
Choice A reason : This statement is incorrect because neither heparin nor warfarin dissolves clots. They prevent the formation of new clots and the growth of existing clots.
Choice B reason : This statement is not accurate. Heparin and warfarin do not enhance each other's effects. They work in different pathways of the clotting cascade. Heparin acts quickly, whereas warfarin takes several days to reach therapeutic levels.
Choice C reason : While seeking clarification from a provider is a part of good nursing practice, it is not the most informative response for the client. The nurse should provide education based on their knowledge and available information.
Choice D reason : This is the correct response. Heparin acts quickly and is used to stabilize the patient while waiting for warfarin to reach therapeutic levels, which is monitored by the international normalized ratio (INR) and usually takes several days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason : Documenting the frequency of blood pressure measurements is crucial for monitoring trends and identifying any changes that may indicate a health issue. It helps in assessing the effectiveness of interventions and in making informed clinical decisions.
Choice B reason : Recording the interventions implemented in response to a high blood pressure reading is important for continuity of care. It ensures that all healthcare providers are aware of the actions taken and can evaluate their effectiveness.
Choice C reason : Noting the patient's response to interventions provides insight into the efficacy of the treatment plan. It is essential for adjusting care plans and for healthcare providers to understand the patient's progress.
Choice D reason : Identifying the person who obtained the blood pressure reading is a part of proper documentation practices. It allows for accountability and follow-up if there are any questions or concerns about the reading.
Choice E reason : The site where the blood pressure was taken can affect the reading. Documenting this information helps to ensure that readings are consistent and comparable over time. It is also important in case an alternative site needs to be used in future measurements.
Correct Answer is A
Explanation
Choice A reason : Hepatomegaly, or the enlargement of the liver, is a common finding in right-sided heart failure. This condition occurs because the heart does not pump blood effectively, leading to congestion and increased pressure in the venous system, including the hepatic veins. As a result, the liver becomes engorged with blood, causing it to enlarge. The normal liver span in adults is about 10-12 cm in the midclavicular line, and any measurement above this can indicate hepatomegaly.
Choice B reason : Orthopnea, which is shortness of breath while lying flat, is more commonly associated with left-sided heart failure. In right-sided heart failure, symptoms are more related to systemic congestion, such as swelling in the legs and abdomen, rather than pulmonary symptoms like orthopnea.
Choice C reason : Dyspnea, or difficulty breathing, can be a symptom of both left and right-sided heart failure. However, in the context of right-sided heart failure, dyspnea is usually due to the accumulation of fluid in the abdominal cavity (ascites) and the increased pressure in the abdominal veins, which can compress the diaphragm and make breathing difficult.
Choice D reason : Frothy sputum is typically not a symptom of right-sided heart failure. It is more indicative of pulmonary edema, which is associated with left-sided heart failure. In right-sided heart failure, the primary issues are related to the systemic circulation and venous congestion.
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