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After teaching a group of nursing students about heparins, the instructor determines that the teaching was successful when the students identify which of the following as an example of a low-molecular-weight heparin (LMWH)? Select all that apply.
- A. Dalteparin
- B. Streptokinase
- C. Enoxaparin
- D. Warfarin
- E. Tinzaparin
Correct Answer: A,C,E
Rationale: Dalteparin, enoxaparin, and tinzaparin are all examples of LMWHs. Streptokinase is a thrombolytic; warfarin is an oral anticoagulant.
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A nurse is conducting an in-service presentation about hemostasis. The nurse determines that the teaching was successful when the class identifies a thrombus as which of the following?
- A. Damage to a blood vessel
- B. Formation of a blood clot
- C. Cessation of bleeding
- D. Coagulation cascade
Correct Answer: B
Rationale: A thrombus refers to the formation of a blood clot, sometimes from damage, in a vessel that impedes blood flow.
A client is experiencing an overdosage of heparin. The nurse would expect to administer which of the following?
- A. Vitamin K1
- B. Protamine
- C. Ticlopidine
- D. Tenecteplase
Correct Answer: B
Rationale: Heparin overdosage is treated with protamine, which neutralizes heparin's anticoagulant effects.
A nurse is caring for a client prescribed warfarin. The nurse would instruct the client that which of the following foods are high in vitamin K?
- A. Dairy products
- B. Root vegetables
- C. Green leafy vegetables
- D. Fruits and cereals
Correct Answer: C
Rationale: The nurse should inform the client that green leafy vegetables are high in vitamin K, which can affect warfarin's efficacy.
A client is prescribed an anticoagulant. In which of the following situations would the nurse hold the drug and notify the physician? Select all that apply.
- A. PT exceeds 1.5 times the control value.
- B. PT is less than 1.5 times the control value.
- C. There is evidence of bleeding.
- D. INR is less than 3.0.
- E. INR is greater than 3.0.
Correct Answer: A,C,E
Rationale: The nurse should withhold the drug and contact the physician if any of the following occur: the PT exceeds 1.5 times the control value, there is evidence of bleeding, or the INR is greater than 3.0.
A client in a health care facility is receiving the thrombolytic drug reteplase. Which nursing diagnosis would be most likely?
- A. Anxiety
- B. Constipation
- C. Disturbed Sensory Perception
- D. Ineffective Tissue Perfusion
Correct Answer: A
Rationale: The nursing diagnoses for a client receiving the thrombolytic drug reteplase should include Anxiety, as thrombolytic therapy can be stressful due to its critical nature.