The client diagnosed with deep vein thrombosis asks the nurse, "How does heparin work to help with my blood clot?" Which response is most accurate? "Heparin:

A. Heparin does not actually "thin" the blood in the sense of reducing viscosity. Instead, it works by inhibiting certain factors in the coagulation cascade, preventing clot formation. Thus, this response does not accurately describe how heparin functions.

B. Heparin works by activating antithrombin III, which inhibits thrombin and factor Xa, thereby preventing the formation of new clots. It does not dissolve existing clots but helps to prevent the enlargement of existing ones and the formation of new clots.
C. Heparin does not decrease the number of platelets; rather, it interferes with the clotting process by inhibiting specific clotting factors. Platelets may still be present, but their ability to form clots is inhibited by the action of heparin.
D. Heparin does not dissolve existing clots; that function is typically performed by thrombolytic agents. Heparin primarily prevents new clot formation and the extension of existing clots. Additionally, it does not decrease platelet formation.

A. While anxiety can exacerbate feelings of breathlessness, treating anxiety does not address the
underlying issue of respiratory distress. It is important to first stabilize the client’s respiratory condition
before managing anxiety.
B. Auscultating breath sounds can provide valuable information regarding the client’s respiratory status. However, in an emergency situation, immediate interventions to stabilize the client should take precedence over assessments, especially since the vital signs indicate significant distress.

C. Elevating the head of the bed can help improve respiratory effort by allowing better lung expansion and reducing the work of breathing. Given the client’s low oxygen saturation and signs of respiratory distress, this intervention can provide immediate relief and improve oxygenation.
D. While this may be necessary if the client's condition worsens or does not improve, it is not the first action to take. Preparing for mechanical ventilation is a more advanced intervention and should only occur after initial stabilization efforts have been made.