A nurse is caring for a client who has deep vein thrombosis.
The client has been receiving 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.”.
“I will ask the charge nurse to call your provider and get an explanation.”.
“Heparin enhances the effects of the warfarin.”.
“Heparin will be continued until the warfarin reaches a therapeutic level.”. . .
The Correct Answer is D
Choice A rationale
Neither heparin nor warfarin work to dissolve clots that have already formed. Instead, they work by reducing the blood’s ability to clot, preventing the formation of new clots and the growth of existing ones.
Choice B rationale
While it’s important for healthcare providers to communicate and explain treatments, it’s not necessary for the charge nurse to call the provider for an explanation in this case. The nurse should be able to explain the rationale for the medication regimen.
Choice C rationale
Heparin does not enhance the effects of warfarin. Both are anticoagulants, but they work in different ways and do not enhance each other’s effects.
Choice D rationale
Heparin will be continued until the warfarin reaches a therapeutic level. Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent harmful clots from forming in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually takes about 3 days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking less than the recommended dose initially may not provide the desired therapeutic effect and could lead to misunderstanding about the effectiveness of the herbal product.
Choice B rationale
While it’s true that some herbal products should not be taken with prescription medications due to potential interactions, this is not the best way to identify allergic or other adverse reactions.
Choice C rationale
While checking with a reputable pharmacist is always a good idea when starting any new medication or supplement, it is not the best way to identify allergic or other adverse reactions.
Choice D rationale
Using only one herbal preparation at a time is the best way to identify allergic or other adverse reactions. If multiple herbal products are started at the same time and an adverse reaction occurs, it would be difficult to determine which product caused the reaction.
Correct Answer is A
Explanation
Choice A rationale
The patient experiencing anaphylaxis is having difficulty breathing due to bronchoconstriction in response to the allergen. Anaphylaxis is a severe allergic reaction that can cause bronchoconstriction, leading to difficulty in breathing. This is a direct response to the allergen, causing the airways to narrow and making it hard for the patient to breathe.
Choice B rationale
While a rapid fall in blood pressure, also known as hypotension, can occur during anaphylaxis, it does not directly cause difficulty in breathing. Hypotension in anaphylaxis is due to the release of histamines which cause vasodilation and increased capillary permeability, leading to fluid leakage from the capillaries into the tissues, reducing the volume of blood returning to the heart.
Choice C rationale
Reflex tachycardia is a compensatory response by the body to a decrease in blood pressure, not a direct cause of difficulty in breathing. It is the body’s attempt to maintain adequate perfusion by increasing the heart rate.
Choice D rationale
Seizures are not a typical symptom of anaphylaxis. While severe anaphylaxis can lead to a loss of consciousness, it does not cause seizures.
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