A nurse is reinforcing teaching about warfarin with a client who has a new onset of atrial fibrillation. Which of the following statements should the nurse include in the teaching?
"Warfarin dissolves clots in the bloodstream."
"This medication slows the response of the ventricles to the fast atrial impulses."
"Warfarin helps prevent strokes in clients who have atrial fibrillation."
"This medication will help maintain a normal heart rhythm."
The Correct Answer is C
Choice A reason : The statement that warfarin dissolves clots in the bloodstream is incorrect. Warfarin does not dissolve existing clots. Instead, it is an anticoagulant that works by decreasing the production of certain clotting factors in the blood, which helps prevent the formation of new clots.
Choice B reason : This statement is not accurate regarding the action of warfarin. Warfarin does not affect the electrical impulses of the heart. Medications that slow the response of the ventricles to fast atrial impulses are typically antiarrhythmic drugs, not anticoagulants like warfarin.
Choice C reason : This is the correct statement. Warfarin is prescribed for clients with atrial fibrillation to reduce the risk of stroke. Atrial fibrillation increases the risk of forming blood clots in the heart, which can then travel to the brain, causing a stroke. Warfarin's anticoagulant effect helps to prevent these clots from forming.
Choice D reason : Warfarin does not help maintain a normal heart rhythm. It is not an antiarrhythmic drug but an anticoagulant. The purpose of warfarin in atrial fibrillation is to prevent stroke by reducing the risk of clot formation, not to correct the heart rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.
Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.
Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.
Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total drops (gtt) the nurse needs to administer. This is done by multiplying the volume of the solution (400 mL) by the drop factor (60 gtt/mL). So, 400 mL × 60 gtt/mL = 24000 gtt.
Step 2 is to calculate the total time in minutes over which the IV should be administered. Since there are 60 minutes in an hour, 8 hours is equivalent to 8 hours × 60 min/hour = 480 minutes.
Step 3 is to calculate the rate at which the IV should be administered. This is done by dividing the total drops by the total time. So, 24000 gtt ÷ 480 min = 50 gtt/min.
The nurse should set the manual IV infusion to deliver approximately 50 gtt/min.
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