A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion.
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 give?
Heparin does not dissolve clots. It stops new clots from forming.
It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.
A pharmacist is the person to answer that querry
The oral medication you will take after this IV will dissolve the clot.
The Correct Answer is A
This question requires an understanding of the mechanism of action of anticoagulants. It evaluates the nurse's ability to differentiate between anticoagulants, which prevent thrombus extension, and thrombolytics, which are specifically designed to lyse existing fibrin clots within the vascular system.
Choice A rationale
Heparin is an anticoagulant that binds to antithrombin III, accelerating the inactivation of thrombin and factor Xa. It effectively prevents the propagation of existing clots and the formation of new ones but lacks fibrinolytic properties to dissolve established thrombi.
Choice B rationale
Heparin has an immediate onset of action when administered via continuous IV infusion. Therapeutic blood levels, typically measured by an activated partial thromboplastin time (aPTT), are achieved quickly, often within hours, not days, of starting the infusion.
Choice C rationale
While pharmacists are experts in medication, the nurse is responsible for patient education regarding the therapy being administered. Deferring to the pharmacist fails to provide the immediate, necessary clarification of the medication's therapeutic intent required for informed patient care.
Choice D rationale
Oral anticoagulants, such as warfarin, are also anticoagulants rather than thrombolytics. Like heparin, they work to prevent future coagulation and do not have the pharmacological capacity to actively dissolve or break down a pre-existing venous blood clot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This question assesses knowledge of drug contraindications. It requires identifying the liver as the primary site of acetaminophen metabolism and recognizing that in patients with severe hepatic impairment, the risk of hepatotoxicity is drastically increased, necessitating an alternative analgesic to ensure patient safety and prevent failure.
Choice A rationale
Acetaminophen is a safe and effective antipyretic for patients with high fever. A fever of 103.4 degrees F is not a contraindication for acetaminophen, as it is standard practice to use this medication to reduce febrile responses in hospitalized patients.
Choice B rationale
Acetaminophen is an effective analgesic for postoperative pain and does not have the adverse gastrointestinal or coagulation side effects associated with NSAIDs. It is typically a safe and appropriate choice for pain management in patients recovering from abdominal surgical procedures.
Choice C rationale
Acetaminophen is metabolized in the liver. In severe hepatitis, hepatic function is critically impaired, significantly increasing the risk of toxic metabolite accumulation. Therefore, acetaminophen is contraindicated, and an alternative analgesic must be selected to prevent further liver damage in the patient.
Choice D rationale
Acetaminophen does not inhibit platelet aggregation or affect the coagulation cascade. It is an appropriate analgesic choice for patients with deep vein thrombosis, as it does not interfere with their anticoagulant therapy or pose a risk of bleeding complications.
Correct Answer is C
Explanation
This question focuses on the patient education requirements for thiazide diuretics. It requires identifying the physiological side effects of diuresis, specifically frequency and nocturia, and how to structure medication administration to maximize therapeutic adherence while maintaining the patient's comfort and sleep quality.
Choice A rationale
Monitoring the therapeutic effect of hydrochlorothiazide is best achieved through daily weight monitoring. Weekly measurements are insufficient to detect fluid retention or rapid weight changes, which are early indicators of potential heart failure or medication ineffectiveness in hypertensive patients.
Choice B rationale
Muscle pain is not an expected adverse effect of hydrochlorothiazide. It may indicate electrolyte disturbances, such as hypokalemia, which is a known risk of thiazide diuretics. Patients must report muscle pain so the nurse can assess serum potassium levels.
Choice C rationale
Hydrochlorothiazide increases urine production. Taking the medication early in the day prevents nocturia, which is the frequent need to urinate at night. This instruction significantly improves the patient's quality of life and adherence to the prescribed daily treatment plan.
Choice D rationale
Hydrochlorothiazide can be taken with or without food. Taking it with food is often recommended if the patient experiences minor gastrointestinal upset. There is no pharmacological or clinical requirement for this medication to be taken strictly on an empty stomach.
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