A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. 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 give?

"It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.

"The oral medication you will take after this IV will dissolve the clot."

"Heparin does not dissolve clots. It stops new clots from forming."

"A pharmacist is the person to answer that question.'

Answer and Explanation

The Correct Answer is C

C. Heparin is an indirect thrombin inhibitor that prevents clot formation. It does not dissolve existing clots.
A. The onset of action of heparin is immediate
B. The oral anticoagulants also don’t dissolve the clot
D. The nurse should also understand the pharmacology of the drugs she or he is administering.

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Correct Answer is A

Explanation

Aspirin has an antiplatelet effect. It prevents aggregation of platelets and hence the formation for the primary platelets plug. This prevent formation of thrombus as a complication of an unstable atherosclerotic plaques.
The other actions of aspirin are not related to MI

A. Assist the client to a side-lying position. B. Hold the dropper 2 cm (1 in) above the naris. C. Tell the client to blow her nose gently before the instillation. D. Instruct the client to stay in the same position for 2 min.

Correct Answer is C

Explanation

Rationale-blowing the nose clears any mucus plugs allowing for optimal absorption
A. Lying on the side post application may lead to spillage of the applied drop
B. Holding the dropper too far leads to spillage with too little medication getting to the desired area
D. Tilting the head too long may lead to unnecessary irritation

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A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. 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 give?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a history of myocardial infarction (Ml) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medications?

Correct Answer is A

Explanation

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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