A nurse is caring for a client who has a deep vein thrombosis, who received IV heparin for the past 5 days, and now has a new prescription for oral warfarin in addition to the heparin. The client asks the nurse if both medications are necessary. Which of the following is an appropriate response by the nurse?

"Heparin enhances the effects of the warfarin."

"Both heparin and warfarin work together to dissolve the clots."

"Heparin will be continued until the warfarin reaches a therapeutic level!"

"I will ask the charge nurse to call your provider and get an explanation"

Answer and Explanation

The Correct Answer is C

A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.

B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.

C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.

D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.

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Correct Answer is A

Explanation

A) The client should use an electric razor while on this medication:
Using an electric razor is recommended for clients taking warfarin because it reduces the risk of cuts and bleeding, which can be difficult to control due to the anticoagulant effects of warfarin. This advice helps minimize the risk of injury and excessive bleeding.

B) Warfarin increases the risk for deep vein thrombosis:
Warfarin is an anticoagulant that is actually used to prevent and treat deep vein thrombosis (DVT) and other thromboembolic conditions. This statement is incorrect because warfarin reduces the risk of clot formation, rather than increasing it.

C) Nose bleeds are common during initial treatment:
While nosebleeds can occur as a side effect of warfarin due to its anticoagulant properties, they are not considered common or normal. Persistent or frequent nosebleeds should be reported to a healthcare provider, as they may indicate that the dosage needs adjustment.

D) If he misses a dose, he should double the dose at the next scheduled time:
Doubling the dose of warfarin if a dose is missed is not recommended. Doing so can significantly increase the risk of bleeding. The correct action for a missed dose is to take it as soon as remembered, but if it is close to the time for the next dose, skip the missed dose and continue with the regular schedule. Clients should follow specific instructions from their healthcare provider regarding missed doses.

A. "Apply the ointment in a thin line into the conjunctival sac." B. "Keep your eye open for 30 sec after instilling the ointment." C. "Use a sterile glove and applicator to apply the antibiotic ointment." D. "Always wipe from the outer to the inner canthus when wiping away secretions."

Correct Answer is A

Explanation

A) "Apply the ointment in a thin line into the conjunctival sac":
This instruction is correct for applying ophthalmic ointments. Placing the ointment in a thin line along the conjunctival sac ensures proper distribution and contact with the affected area.

B) "Keep your eye open for 30 sec after instilling the ointment":
Keeping the eye open for a brief period after instillation helps the ointment spread across the eye surface. This statement indicates understanding of the proper technique for applying ophthalmic ointments and does not require further instruction.

C) "Use a sterile glove and applicator to apply the antibiotic ointment":
Using a sterile glove and applicator ensures that the application is done in a sterile manner, reducing the risk of introducing further infection. This statement indicates a need for further instruction, as ophthalmic ointments are typically applied using clean hands or disposable, sterile applicators rather than sterile gloves.

D) "Always wipe from the outer to the inner canthus when wiping away secretions":
Wiping from the outer to the inner canthus helps prevent contamination of the unaffected eye. This statement demonstrates understanding of proper eye care techniques and does not require further instruction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

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A nurse is collecting data from a client prior to the administration of digoxin. Which of the following findings should the nurse report to the provider?

A nurse is reinforcing teaching with a client who is to self-administer regular insulin and NPH insulin from the same syringe. Which of the following instructions should the nurse provide?

A nurse is reinforcing teaching with a client who is to start taking enteric-coated naproxen for rheumatoid arthritis. Which of the following client statements by the client indicates a need for further teaching?

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