A nurse is caring for a client who is diagnosed with a deep vein thrombosis (DVT) and is receiving heparin. 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?
"Depending on the level of your PT/INR, the clot will begin to dissolve."
"After the first dose, the clot will begin to dissolve."
"It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level."
"Heparin does not dissolve clots. It stops new clots from forming."
The Correct Answer is D
A. "Depending on the level of your PT/INR, the clot will begin to dissolve.": This response is misleading, as heparin's effect is not primarily monitored by PT/INR; rather, heparin is monitored by activated partial thromboplastin time (aPTT). Moreover, heparin does not directly dissolve clots; it prevents further clot formation.
B. "After the first dose, the clot will begin to dissolve.": This statement inaccurately suggests that heparin has an immediate effect on dissolving existing clots. While heparin acts quickly to inhibit further clotting, it does not lead to the dissolution of clots after the first dose.
C. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.": This is not accurate for heparin, which has an immediate effect on coagulation. While the therapeutic effects can be optimized over several days, heparin begins to work right away to prevent further clotting.
D. "Heparin does not dissolve clots. It stops new clots from forming.": This response accurately describes the mechanism of action of heparin. Heparin prevents the extension of existing clots and the formation of new clots, but it does not actively dissolve clots. This clarification is essential for the client’s understanding of their treatment and expectations regarding DVT management.
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Correct Answer is D
Explanation
A) Pulse oximetry of 92%: While a pulse oximetry reading of 92% is slightly below normal, it is not a definitive reason to hold verapamil. This reading indicates mild hypoxemia, but it does not directly contraindicate the use of verapamil. Other factors should be considered before making a decision based solely on this value.
B) Pulse of 78: A pulse rate of 78 beats per minute is within the normal range for adults and does not warrant holding verapamil. This finding alone does not indicate any immediate concerns related to the administration of the medication.
C) Respiratory rate of 12: A respiratory rate of 12 breaths per minute is within the normal range for adults. This finding does not provide any indication that verapamil should be withheld. It is important to consider other clinical factors when assessing the appropriateness of medication administration.
D) History of myocardial infarction a week ago: Verapamil, a calcium channel blocker, can have significant effects on cardiac function. Administering it to a client who recently experienced a myocardial infarction (heart attack) could exacerbate cardiac issues and lead to complications. Therefore, it is crucial to hold the medication and consult with the healthcare provider before proceeding.
Correct Answer is A
Explanation
A) Inhibits platelet aggregation: The primary benefit of aspirin following a myocardial infarction (MI) is its ability to inhibit platelet aggregation. By preventing platelets from clumping together, aspirin reduces the risk of further clot formation, which is critical in preventing additional cardiac events and improving overall cardiovascular outcomes.
B) Anti-inflammatory properties: While aspirin does have anti-inflammatory effects, this is not the primary reason it is prescribed after an MI. The focus in the post-MI setting is on its role in preventing clot formation rather than addressing inflammation.
C) Antiemetic: Aspirin is not an antiemetic and does not alleviate nausea or vomiting. Clients experiencing gastrointestinal issues or nausea would require different medications for those symptoms.
D) Anti-pyretic: Although aspirin can reduce fever, this effect is not the primary concern in the post-MI setting. The immediate goal is to improve heart health and prevent further thrombotic events, making platelet inhibition the most relevant benefit.