A nurse is assessing a client who is receiving heparin therapy for deep-vein thrombosis.
Which of the following findings should indicate to the nurse that the therapy is effective?
Platelets within the expected reference range.
Decreased INR.
Presence of pedal pulses bilaterally.
Reduced calf circumference.
The Correct Answer is D
Heparin therapy is used to prevent thrombus propagation and distal embolization while allowing the endogenous fibrinolytic system to dissolve existing clots in deep-vein thrombosis (DVT)1.
A reduction in calf circumference may indicate that the clot is dissolving and the therapy is effective.
Choice A is wrong because platelets within the expected reference range do not necessarily indicate that heparin therapy for DVT is effective.
Choice B is wrong because INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin therapy.
Choice C is wrong because the presence of pedal pulses bilaterally does not necessarily indicate that heparin therapy for DVT is effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should monitor the client for fever as an indication that the client is experiencing an acute infusion reaction to IV amphotericin
Fever is a common symptom of an infusion reaction to amphotericin
Choice A is wrong because pedal edema is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice C is wrong because hyperglycemia is not a commonly reported symptom of an acute infusion reaction to amphotericin
Choice D is wrong because dry cough is not a commonly reported symptom of an acute infusion reaction to amphotericin
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale:
- This response is not appropriate because it is judgmental and may make the client feel defensive.
- It is important for the nurse to respect the client's right to make their own decisions about their health care.
- Telling the client what they should do can undermine their autonomy and potentially damage the nurse-client relationship.
- It's crucial for the nurse to remain objective and avoid imposing their personal opinions or beliefs onto the client.
Choice B rationale:
- This response is also not appropriate because it is using scare tactics to try to persuade the client to get the vaccine.
- This approach can be counterproductive and may further alienate the client.
- It's important to provide accurate information about the risks and benefits of the vaccine in a neutral and non-threatening manner.
Choice C rationale:
- This is the most appropriate response because it acknowledges the client's right to refuse the vaccine while still encouraging them to get it.
- It also demonstrates respect for the client's autonomy and validates their feelings.
- This approach is more likely to foster a positive nurse-client relationship and keep the door open for future discussions about vaccination.
Choice D rationale:
- This response is not accurate because the influenza vaccine is not mandatory for all clients before discharge.
- It is important for the nurse to provide accurate information to the client.
- Threatening the client with an against medical advice form is not appropriate and may be considered a form of coercion.
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