The client diagnosed with deep vein thrombosis asks the nurse, "How does heparin work to help with my blood clot?" Which response is most accurate? "Heparin:

makes the blood less thick and easier to flow."

does not thin the blood: it prevents new clots from forming."

decreases the number of platelets so the blood clots more slowly."

dissolves the clot and decreases the formation of platelets."

Answer and Explanation

The Correct Answer is B

A.   Heparin does not actually "thin" the blood in the sense of reducing viscosity. Instead, it works by inhibiting certain factors in the coagulation cascade, preventing clot formation. Thus, this response does not accurately describe how heparin functions.

B.   Heparin works by activating antithrombin III, which inhibits thrombin and factor Xa, thereby preventing the formation of new clots. It does not dissolve existing clots but helps to prevent the enlargement of existing ones and the formation of new clots.
C.   Heparin does not decrease the number of platelets; rather, it interferes with the clotting process by inhibiting specific clotting factors. Platelets may still be present, but their ability to form clots is inhibited by the action of heparin.
D.   Heparin does not dissolve existing clots; that function is typically performed by thrombolytic agents. Heparin primarily prevents new clot formation and the extension of existing clots. Additionally, it does not decrease platelet formation.

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Correct Answer is C

Explanation

A. While epinephrine is crucial in cases of anaphylaxis, it should not be the first action taken. The immediate priority is to stop the offending medication.
B. While assessing vital signs is important, it is not the first action. The primary concern is to halt the exposure to the potential allergen.
C. The first action in this situation should be to immediately stop the infusion of the antibiotic. This prevents further exposure to the allergen and is critical to managing the potential anaphylactic reaction.

D. While providing oxygen may be necessary later if the client is hypoxic, the immediate priority is to stop the infusion of the antibiotic first. Administering oxygen is important but comes after halting the offending agent.

A. increased. B. given as prescribed. C. cut in half. D. held.

Correct Answer is D

Explanation

A. An INR of 5.0 indicates that the blood is significantly thinner than the therapeutic range (typically 2.0 to 3.0 for DVT treatment). Increasing the dose of warfarin would further increase the risk of bleeding.
B. Continuing with the prescribed dose of 2.5 mg is not appropriate at this time. The INR is above the safe therapeutic range, indicating a need for adjustment, not maintenance of the current dose.
C. While reducing the dose may be necessary, cutting it in half may not adequately address the high INR. The more appropriate action would involve holding the dose or significantly adjusting it based on the INR and clinical guidelines.
D. An INR of 5.0 is a critical value that suggests the client is at an increased risk of bleeding. The appropriate action in this case is to hold the warfarin dose and notify the healthcare provider for further evaluation and management. Depending on clinical protocols, the provider may recommend administering vitamin K to reverse the effects of warfarin, especially if there are signs of bleeding or if the INR is critically high.

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The client diagnosed with deep vein thrombosis asks the nurse, "How does heparin work to help with my blood clot?" Which response is most accurate? "Heparin:

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Naxlex Comprehensive Predictor Exams

Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

Correct Answer is C

Explanation

A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be:

Correct Answer is D

Explanation

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