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 C

Explanation

Choice A rationale

Administering the prescribed antibiotic early might not be the most immediate action. While antibiotics can help treat an infection, it’s crucial to first confirm the presence of an infection before starting antibiotic therapy.

Choice B rationale

Applying a sterile dressing to the area is important, but it’s not the priority nursing action. Dressings help protect the wound from further contamination, but they do not address the underlying issue of a potential infection.

Choice C rationale

Reporting the finding to the care provider is the priority nursing action. The symptoms described - a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch - suggest a possible infection. Immediate reporting allows for prompt evaluation and treatment, which is crucial in preventing further complications.

Choice D rationale

Obtaining a culture of the incision might be necessary to identify the specific causative agent of the infection, but it’s not the priority action. It’s more important to first report the findings to the care provider.

A. 0640 B. 0650 C. 0700 D. 0710

Correct Answer is A

Explanation

The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404

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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 caring for a patient who had an above-the-knee amputation (AKA) five days ago. The nurse notices a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch. What is the priority nursing action in this situation?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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

Correct Answer is A

Explanation

The client diagnosed with peripheral arterial disease (PAD) has a new prescription for clopidogrel. What information should the nurse include when teaching the client about this medication?

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