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
Explanation
Choice A reason : S1 represents the sound made by the closure of the atrioventricular valves (mitral and tricuspid valves) and is not the sound associated with the closure of the aortic and pulmonic valves.
Choice B reason : S2 is the sound heard when the aortic and pulmonic valves close. It is often described as a "dub" and occurs at the end of ventricular systole.
Choice C reason : S3 is a rare extra heart sound that follows S2 and usually indicates an increase in left ventricular filling pressure, which can be found in conditions such as heart failure.
Choice D reason : S4 is another extra heart sound that occurs just before S1. It is typically associated with a stiff or hypertrophic ventricle and is not related to the closure of the aortic and pulmonic valves
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Monitoring cholesterol levels is essential while taking lisinopril. This medication is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure, heart failure, and heart attack. Regular monitoring helps assess the impact of lisinopril on lipid levels and overall cardiovascular health. Elevated cholesterol can contribute to heart disease, so monitoring allows for timely interventions and adjustments in treatment.
Choice C reason: Potassium-rich foods are relevant because lisinopril can affect potassium levels. ACE inhibitors may lead to hyperkalemia (high potassium levels), especially in patients with impaired kidney function. Encouraging potassium-rich foods helps maintain a balance and prevent complications.
Choice D reason: Reporting a persistent dry cough is crucial. Lisinopril is associated with a common side effect: a dry, persistent cough. This occurs due to increased levels of bradykinin, a substance affected by ACE inhibitors. If the client experiences this cough, it's essential to notify the doctor for potential medication adjustments.
Choice E reason: Monitoring blood pressure aligns with the purpose of lisinopril. Regular blood pressure checks help assess the effectiveness of the medication in controlling hypertension. Consistent monitoring ensures timely adjustments and prevents complications related to high blood pressure.
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