Nursing Elites

1. A client with thrombophlebitis receiving heparin by continuous IV infusion asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

• A. It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.
• B. A pharmacist is the person to answer that question.
• C. Heparin does not dissolve clots. It stops new clots from forming.
• D. The oral medication you will take after this IV will dissolve the clot.

Correct answer: C

Rationale: The correct response is C. Heparin does not dissolve clots; it prevents new clots from forming. Heparin works by inhibiting the formation of new clots and the extension of existing clots, rather than directly dissolving them. The client should be informed that the purpose of heparin therapy is to prevent the clot from getting larger and to reduce the risk of new clots forming. Choices A, B, and D are incorrect. Choice A talks about reaching a therapeutic blood level of heparin, which is not related to clot dissolution. Choice B deflects the question to a pharmacist without providing relevant information. Choice D inaccurately suggests that an oral medication will dissolve the clot, which is not the mechanism of action for heparin.

2. Which of the following is the antidote for Heparin toxicity?

• A. Protamine
• B. Methylene blue
• C. N-acetylcysteine
• D. Glucagon

Correct answer: A

Rationale: Protamine is the specific antidote for Heparin toxicity. Heparin is an anticoagulant medication, and if an overdose occurs or if there is excessive bleeding due to Heparin use, protamine, a positively charged molecule, can neutralize the anticoagulant effects of Heparin by forming a complex with it. This binding prevents Heparin from further inhibiting coagulation factors and helps in reversing its effects.

3. A patient is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

• A. Hemoglobin
• B. Prothrombin time (PT)
• C. Bleeding time
• D. Activated partial thromboplastin time (aPTT)

Correct answer: B

Rationale: The correct answer is to monitor Prothrombin time (PT) when a patient is on warfarin therapy. Warfarin affects blood clotting, and PT is used to assess the therapeutic effect of this medication. Hemoglobin (Choice A) is not directly affected by warfarin therapy and does not reflect its therapeutic effect. Bleeding time (Choice C) measures the time it takes for bleeding to stop after a standardized cut and is not specific to warfarin therapy. Activated partial thromboplastin time (aPTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

4. During the repair of a skin laceration, a client receives a local anesthetic of Lidocaine. For which of the following adverse reactions should the nurse monitor the client?

• A. Seizures
• B. Tachycardia
• C. Hypertension
• D. Fever

Correct answer: A

Rationale: Seizures are a potential adverse reaction following the administration of local anesthetics like Lidocaine. This adverse effect is important to monitor as it can be life-threatening and requires immediate intervention. It is crucial for the nurse to be vigilant in recognizing any signs of seizure activity to ensure the client's safety and well-being.

5. A client has a new prescription for Calcitonin-salmon for postmenopausal osteoporosis. Which of the following instructions should the nurse include in the teaching?

• A. Swallow tablets on an empty stomach with plenty of water.
• B. Watch for skin rash and redness when applying calcitonin-salmon topically.
• C. Mix the liquid medication with juice and take it after meals.
• D. Alternate nostrils each time calcitonin-salmon is inhaled.

Correct answer: D

Rationale: Calcitonin-salmon is commonly administered intranasally for postmenopausal osteoporosis. It is essential to alternate nostrils daily when inhaling the medication to ensure equal distribution and optimal absorption. This technique helps prevent irritation and congestion in one nostril and enhances the effectiveness of the medication. Choices A, B, and C are incorrect because calcitonin-salmon is not swallowed, applied topically, or taken as a liquid medication after meals. Therefore, instructing the client to alternate nostrils during inhalation is the most appropriate teaching for this medication.

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