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

"Heparin does not dissolve clots. It stops new clots from forming"

"Heparin will begin dissolving clots over the next 24 hours

"A pharmacist would be a better fit to answer that question.

"It usually takes heparin at least 3 to 4 days to reach a therapeutic blood level."

Answer and Explanation

The Correct Answer is A

Choice A rationale: Heparin is an anticoagulant that prevents new clots from forming but does not dissolve existing clots23.

Choice B rationale: Heparin does not directly dissolve clots23.

Choice C rationale: While a pharmacist can provide medication information, it is incorrect to say they would be a better fit to answer this question as nurses are trained in medication education23.

Choice D rationale: While it’s true that it takes time for heparin to reach a therapeutic blood level, this statement could be misleading because heparin does not dissolve clots23.

So, the correct answer is Choice A, after analysing all choices.

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Correct Answer is B

Explanation

Choice A rationale: While amiodarone is a medication used in the treatment of ventricular fibrillation, it is not the immediate priority in an unresponsive client34.

Choice B rationale: The immediate priority in a client who goes into ventricular fibrillation and is unresponsive is to prepare for defibrillation. This is a life-saving measure that can restore a normal heart rhythm34.

Choice C rationale: Synchronized cardioversion is not the immediate priority in a client who goes into ventricular fibrillation and is unresponsive34.

Choice D rationale: While epinephrine is a medication used in the treatment of ventricular fibrillation, it is not the immediate priority in an unresponsive client34.

So, the correct answer is B, after analysing all choices.

A. To take the tablet with a large amount of water so that it will dissolve right away B. Go to the nearest hospital and take the medication upon reaching the hospital C. To lie or sit and place one tablet under the tongue when chest pain occurs D. if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital

Correct Answer is C

Explanation

Choice A rationale: Nitroglycerin tablets are not typically taken with water. They are designed to dissolve under the tongue for quick absorption into the bloodstream6789.

Choice B rationale: It is not necessary to go to the hospital to take the medication. The medication can be taken at the onset of chest pain6789.

Choice C rationale: This is the correct instruction. At the onset of chest pain, the patient should lie or sit down and place one tablet under the tongue6789.

Choice D rationale: If one tablet does not relieve the pain in 5 minutes, a second tablet may be taken. If the pain continues for another 5 minutes, a third tablet may be used. If the patient still has chest pain after a total of 3 tablets, they should seek immediate medical attention6789.

So, the correct answer is C, after analysing all choices

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

Nursing Test Bank

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