A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Heparin makes the blood less thick and easier to flow.

Heparin dissolves the clot and decreases the formation of platelets.

Heparin does not thin the blood; it prevents new clots from forming.

Heparin decreases the number of platelets so the blood flows more easily.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

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Correct Answer is B

Explanation

Choice A rationale

Pseudomembranous colitis and crystalluria are not typically associated with gentamicin use.

Choice B rationale

Gentamicin can cause ototoxicity, which can manifest as tinnitus (ringing in the ears), vertigo (a sensation of spinning), and hearing loss. Headaches can also occur as a side effect of gentamicin.

Choice C rationale

While gentamicin can cause nephrotoxicity (kidney damage), which could potentially affect electrolyte levels, a potassium level of 3.5 mg/dL is within the normal range. Therefore, this would not typically be assessed as a toxic effect of gentamicin.

Choice D rationale

Hypoglycemia and cardiac dysrhythmias are not typically associated with gentamicin use.

A. “This must be very difficult for you. I am here if you want to talk.”. B. “Can you tell me why you are so upset?” C. “I am sure everything will be alright. There is no need to cry.”. D. “You will recover.”.

Correct Answer is A

Explanation

Choice A rationale

When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.

Choice B rationale

Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.

Choice C rationale

Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.

Choice D rationale

Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.

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A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a client receiving gentamicin. Which of the following would the nurse assess as potential toxic effects of this medication?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient diagnosed with diabetes has severe peripheral neuropathy resulting in numbness and reduced sensation of the feet. What intervention should the nurse teach the patient to prevent injury as a result of this complication?

The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

The nurse is caring for the following four clients on the nursing unit. Which client is at the highest risk for the development of deep vein thrombosis?

A nurse gives a client 10 units of insulin lispro at 0630. When should the client have breakfast?

A Type 1 diabetic client with a morning (fasting) glucose of 260 mg/dL has been diagnosed with the Somogyi effect from insulin administration. What intervention should the nurse anticipate including in the plan of care?

A client has recently been diagnosed with Type 2 diabetes. What should be the nurse’s initial step when developing an educational plan?