A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Choice A reason : Cleaning dentures in a denture cup is a standard hygiene practice but does not directly address the low WBC count. While maintaining oral hygiene is important, it is not the most critical action related to the client's immunocompromised state⁶.

Choice B reason : Replacing the water in flower vases daily is a good practice to prevent bacterial growth; however, it is recommended to avoid having flowers or plants in the room of an immunocompromised patient due to the risk of exposure to fungi and bacteria⁷.

Choice C reason : Humidifying the room can be beneficial for respiratory comfort, but it must be done with caution in immunocompromised patients. Humidifiers need to be kept clean to prevent the growth of bacteria and fungi, which could be harmful to a patient with a low WBC count⁷.

Choice D reason : Serving cooked fruit with meals is the correct action because cooking fruit can eliminate potential pathogens that the client's compromised immune system may not be able to handle. Raw fruits and vegetables can harbor bacteria and other pathogens, so serving them cooked is a safer option for someone with a low WBC count⁶⁷.

Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.

Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.

Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.

Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.