A nurse is caring for a client who has deep vein thrombosis (DVT). The client has received intravenous (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?
"Both heparin and warfarin work together to dissolve the clots."
"Heparin enhances the effects of the warfarin."
"I will ask the charge nurse to call your provider and get an explanation."
"Heparin will be continued until the warfarin reaches a therapeutic level."
The Correct Answer is D
Choice A reason : This statement is incorrect because neither heparin nor warfarin dissolves clots. They prevent the formation of new clots and the growth of existing clots.
Choice B reason : This statement is not accurate. Heparin and warfarin do not enhance each other's effects. They work in different pathways of the clotting cascade. Heparin acts quickly, whereas warfarin takes several days to reach therapeutic levels.
Choice C reason : While seeking clarification from a provider is a part of good nursing practice, it is not the most informative response for the client. The nurse should provide education based on their knowledge and available information.
Choice D reason : This is the correct response. Heparin acts quickly and is used to stabilize the patient while waiting for warfarin to reach therapeutic levels, which is monitored by the international normalized ratio (INR) and usually takes several days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : The triglyceride level of 130 mg/dL is within the normal range, which is less than 150 mg/dL for adults. Therefore, this result does not place the client at risk for peripheral arterial disease.
Choice B reason : An HDL level of 84 mg/dL is considered good as it is higher than the minimum recommended level of 40 mg/dL for males and 50 mg/dL for females. Higher levels of HDL are protective against heart disease.
Choice C reason : A blood glucose level of 92 mg/dL is within the normal fasting range of 70 to 99 mg/dL. This indicates that the client does not have diabetes, which is a risk factor for peripheral arterial disease.
Choice D reason : An LDL level of 172 mg/dL is considered high since the optimal level for LDL is less than 100 mg/dL. High levels of LDL cholesterol can lead to atherosclerosis, increasing the risk for peripheral arterial disease.
Correct Answer is B
Explanation
Choice A reason : S1 represents the sound made by the closure of the atrioventricular valves (mitral and tricuspid valves) and is not the sound associated with the closure of the aortic and pulmonic valves.
Choice B reason : S2 is the sound heard when the aortic and pulmonic valves close. It is often described as a "dub" and occurs at the end of ventricular systole.
Choice C reason : S3 is a rare extra heart sound that follows S2 and usually indicates an increase in left ventricular filling pressure, which can be found in conditions such as heart failure.
Choice D reason : S4 is another extra heart sound that occurs just before S1. It is typically associated with a stiff or hypertrophic ventricle and is not related to the closure of the aortic and pulmonic valves
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