The nurse notes in the patient’s medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy?

Stabilizing an existing thrombus

Dilating the vessel around the clot

Preventing thrombus formation

Dissolving existing thrombus

Answer and Explanation

The Correct Answer is C

Choice A reason: Stabilizing an existing thrombus is not the primary goal of anticoagulant therapy, which focuses on preventing new clot formation. Thrombolytics dissolve clots, while anticoagulants inhibit clotting factors, making this incorrect, as prevention, not stabilization, is the main therapeutic objective.

Choice B reason: Dilating vessels is not an effect of anticoagulants, which inhibit clotting factors to prevent thrombus formation. Vasodilation is achieved by other drugs like nitrates, making this incorrect, as it does not align with the mechanism or goal of anticoagulant therapy.

Choice C reason: The primary goal of anticoagulant therapy is to prevent thrombus formation by inhibiting clotting factors, reducing the risk of thromboembolism in conditions like atrial fibrillation or DVT. This aligns with the therapeutic purpose, making it the correct goal for the nurse to understand.

Choice D reason: Dissolving existing thrombi is the role of thrombolytic therapy, not anticoagulants, which prevent new clots. Anticoagulants like heparin maintain clot stability but do not lyse clots, making this incorrect, as prevention is the primary focus of anticoagulant therapy.

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Correct Answer is A

Explanation

Choice A reason: A heart rate of 89 beats per minute in a 6-month-old (normal 90–160) is low, indicating potential digoxin toxicity or decreased cardiac output. Withholding digoxin and assessing for symptoms like nausea or arrhythmias is critical to prevent harm, making this the correct action for the nurse.

Choice B reason: Withholding digoxin and re-evaluating in 4 hours delays necessary assessment for toxicity or cardiac compromise in a 6-month-old with a low heart rate (89 bpm). Immediate evaluation is needed, making this incorrect, as it risks missing critical signs of digoxin-related complications.

Choice C reason: Administering half the digoxin dose is unsafe without confirming the cause of the low heart rate (89 bpm). In infants, this could worsen toxicity or bradycardia. Withholding and assessing for toxicity is safer, making this an incorrect action for managing potential digoxin complications.

Choice D reason: A heart rate of 89 bpm is below normal for a 6-month-old (90–160 bpm), and administering digoxin risks worsening bradycardia or toxicity. Normal infant heart rates are higher, making this incorrect, as the nurse must withhold the dose and assess for complications.

A. Encouraging increased mobility B. Dietary and fluid restrictions C. Cessation of intravenous drug use D. Cessation of hormonal supplements

Correct Answer is B

Explanation

Choice A reason: Increased mobility is beneficial for general health but must be cautious in heart failure to avoid overexertion, which can exacerbate cardiac strain and fluid overload. Dietary and fluid restrictions are more critical to manage volume status, making mobility a secondary focus in discharge teaching for heart failure.

Choice B reason: Dietary and fluid restrictions, particularly low-sodium diets and limited fluid intake, are essential in heart failure to reduce fluid overload, preload, and cardiac workload. This prevents exacerbations like pulmonary edema, making it a priority lifestyle modification to include in discharge teaching for effective heart failure management.

Choice C reason: Cessation of intravenous drug use is relevant for specific populations but not a general heart failure management strategy. It does not directly address fluid overload or cardiac workload, unlike dietary and fluid restrictions, making it an incorrect focus for routine discharge teaching in heart failure.

Choice D reason: Cessation of hormonal supplements is not typically relevant to heart failure management unless specific hormones affect fluid balance or cardiac function. Dietary and fluid restrictions directly address the pathophysiology of fluid overload, making this an incorrect lifestyle modification for routine heart failure discharge teaching.

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The nurse notes in the patient’s medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is auscultating a 6-month-old client’s apical heart rate before giving a dose of digoxin and notes that the heart rate is 89 beats per minute. Which action should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching to a client who has heart failure. Which of the following lifestyle modifications should the nurse include in the discharge teaching?

Correct Answer is B

Explanation

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