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A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
- A. 5 minutes.
- B. 10 minutes.
- C. 20 minutes.
- D. 30 minutes.
Correct Answer: C
Rationale: Protamine sulfate neutralizes heparin rapidly, with effects typically seen within 20 minutes of administration. This allows for quick reversal of heparin's anticoagulant effects in cases of bleeding. The other time frames are either too short or too long.
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A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
- A. Operating machinery and driving may be dangerous while taking antihistamines.
- B. Committaking antihistamines even if nasal infection develops.
- C. The effect of antihistamines is not felt until a day later.
- D. Do not use alcohol with antihistamines.
- E. Increase fluid intake to 2,000 mL/day.
Correct Answer: A,D,E
Rationale: Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least 8 glasses per day due to the drying effect of the drug.
The nurse is teaching the client and family how to manage possible nausea and vomiting at home. The nurse should include information about:
- A. Eating frequent, small meals throughout the day.
- B. Eating three normal meals a day.
- C. Eating only cold foods with no odor.
- D. Limiting the amount of fluid intake.
Correct Answer: A
Rationale: Eating frequent, small meals helps prevent nausea by avoiding an empty or overly full stomach, which can trigger vomiting during chemotherapy.
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
- A. Urine output greater than 30 mL/hour.
- B. Systolic blood pressure greater than 110 mm Hg.
- C. Diastolic blood pressure greater than 90 mm Hg.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
- A. Check the dressing and drains for frank bleeding.
- B. Call the physician.
- C. Continue to monitor vital signs.
- D. Start oxygen at 2 L/minute per nasal cannula.
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.