A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as contributing to this lab value?

Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.

Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.

Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.

Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.

Choice A reason : While helping the client identify positive personality traits can be beneficial for self-esteem and long-term recovery, it is not the immediate priority during the acute withdrawal phase. The focus during this time should be on managing withdrawal symptoms and ensuring the client's safety¹.

Choice B reason : Providing for adequate hydration and rest is the priority intervention for a client in alcohol withdrawal. Withdrawal can lead to significant fluid loss due to vomiting and sweating, and rest is essential for the body to recover from the physiological stress of detoxification. Ensuring the client is well-hydrated and rested can prevent complications and aid in the recovery process¹².

Choice C reason : Educating the client about the consequences of alcohol misuse is an important part of treatment but is not the immediate priority during withdrawal. Education is more effective when the client is stable and can participate actively in learning and discussion¹.

Choice D reason : Confronting the use of denial and other defense mechanisms may be part of the therapeutic process but is not the immediate priority during the acute phase of withdrawal. The nurse's immediate concern should be the physical stabilization of the client¹.