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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason : Keeping the client in a high-Fowler's position for 6 hours post-cardiac catheterization is not recommended. After a femoral approach, it's important to keep the leg straight and the patient flat or with the head slightly elevated to prevent bleeding from the catheter insertion site. High-Fowler's position could increase the risk of bleeding and is not conducive to maintaining pressure at the arterial access site.

Choice B reason : Allowing the patient to ambulate around the room immediately after the procedure is contraindicated. The patient is typically required to remain on bed rest with the affected leg straight to prevent bleeding and ensure proper healing of the arterial puncture site. Ambulation is usually restricted for several hours post-procedure.

Choice C reason : Checking pedal pulses every 15 minutes is a critical action following cardiac catheterization via the femoral artery. It ensures that there is adequate blood flow to the extremity and helps to identify any complications such as occlusion or bleeding early. Adequate perfusion is indicated by strong and equal pedal pulses.

Choice D reason : Performing passive range-of-motion exercises for the affected extremity immediately after cardiac catheterization is not recommended. The affected leg should remain straight without bending at the hip to prevent bleeding from the catheter site. Passive range-of-motion could disrupt the vascular integrity at the puncture site and increase the risk of bleeding.

A. The test will be complete in 30 to 60 minutes. B. You may feel a slight tingling while the test is being done. C. The radioactivity from the dye lasts only a few hours. D. I will need to apply electrodes to your chest and extremities.

Correct Answer is D

Explanation

Choice A reason : The statement that the test will be complete in 30 to 60 minutes is incorrect. An ECG is a quick, non-invasive procedure that typically takes only a few minutes to perform.

Choice B reason : The statement about feeling a slight tingling is not accurate for an ECG. This test does not cause any sensations, as it simply records the electrical activity of the heart.

Choice C reason : The mention of radioactivity from dye is not applicable to an ECG. This test does not involve the use of any dyes or radioactive substances. Dyes are typically used in imaging tests like CT scans or MRIs, not ECGs.

Choice D reason : This is the correct statement. For an ECG, electrodes are placed on the patient's chest and extremities to record the electrical activity of the heart. This allows the healthcare provider to assess the heart's rhythm, identify any irregularities, and diagnose conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing an electrocardiogram (ECG) on a client who is experiencing chest pain. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply)

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

A nurse is caring for a client who has hypertension and is to start taking atenolol. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication?

A nurse is reinforcing teaching with a client who has hypertension and inquires if there is a herbal supplement that can be used to help lower blood pressure. The nurse should identify which of the following herbal supplements the client can use to help lower blood pressure :

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)