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A nurse is caring for a patient who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? Which medication should the nurse administer for heparin overdose?
- A. Vitamin K
- B. Iron
- C. Glucagon
- D. Protamine
Correct Answer: D
Rationale: The correct answer is D: Protamine. Protamine is the antidote for heparin overdose. It works by binding to heparin, neutralizing its anticoagulant effects. Vitamin K (choice A) is used to reverse the effects of warfarin, not heparin. Iron (choice B) is used to treat iron deficiency anemia. Glucagon (choice C) is used to treat hypoglycemia. In summary, protamine is specifically indicated for heparin overdose due to its ability to neutralize heparin's anticoagulant effects, making it the appropriate choice in this scenario.
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A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson's stages of psychosocial development in order from birth to adolescence. Arrange Erikson's stages from birth to adolescence.
- A. Identity vs. role confusion
- B. Trust vs. mistrust
- C. Industry vs. inferiority
- D. Autonomy vs. shame and doubt
- E. Initiative vs. guilt
Correct Answer: B,D,E,C,A
Rationale: 1. Trust vs. mistrust comes first as it pertains to infancy and the development of basic trust in caregivers.
2. Autonomy vs. shame and doubt follows, focusing on toddlers developing independence.
3. Initiative vs. guilt is next, focusing on preschoolers exploring and taking initiative.
4. Industry vs. inferiority is about school-aged children developing competence.
5. Identity vs. role confusion is about adolescents forming a sense of self.
Therefore, the correct order is B, D, E, C, A. Other choices are incorrect as they do not align with the chronological order of Erikson's stages.
A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient's NG tube and initiates oral feedings. Which of the following statements should the nurse make? Which statement should the nurse make post-laryngectomy?
- A. You should have no trouble swallowing fluids.
- B. It is no longer possible for you to choke on or aspirate food.
- C. I will add a thickener to your liquids to prevent aspiration.
- D. Tuck your chin when you swallow so you won't choke.
Correct Answer: D
Rationale: The correct answer is D: "Tuck your chin when you swallow so you won't choke." After a laryngectomy, patients have altered anatomy that can affect swallowing. Tucking the chin helps close off the airway during swallowing, reducing the risk of choking. This technique directs the food towards the esophagus instead of the trachea, minimizing the risk of aspiration. Choices A, B, and C are incorrect because they do not address the specific swallowing precautions needed post-laryngectomy. Choice A assumes normal swallowing function, which may not be the case. Choice B is inaccurate as aspiration can still occur post-laryngectomy. Choice C is not specific to the patient's individual needs and may not be necessary.
A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse's priority? Which observation is the priority for epidural analgesia?
- A. The patient's blood pressure is 80/56 mm Hg.
- B. The patient reports lower extremity weakness.
- C. The patient's temperature is 38.2°C (100.8 F).
- D. The patient reports severe itching.
Correct Answer: A
Rationale: The correct answer is A: The patient's blood pressure is 80/56 mm Hg. This is the priority observation because hypotension is a common side effect of epidural analgesia, which can lead to decreased perfusion and compromise fetal well-being. Lower extremity weakness (B) is expected due to the effect of the epidural. Temperature elevation (C) can be due to various factors unrelated to the epidural. Severe itching (D) can be a side effect but is not life-threatening like hypotension.
A nurse is formulating a care plan for a patient recovering from severe burns. Which of the following strategies should the nurse incorporate to provide emotional support? Which strategy provides emotional support for burn recovery?
- A. Engage in conversation with the patient during wound care.
- B. Ensure the patient's room is kept tidy by support staff.
- C. Keep the patient's family informed about his condition.
- D. Rotate the nursing staff to provide the patient with varied interactions.
Correct Answer: A
Rationale: The correct answer is A: Engage in conversation with the patient during wound care. This strategy provides emotional support by offering the patient a distraction and a sense of connection during a potentially painful and distressing procedure. It allows the patient to express their feelings and concerns, fostering a therapeutic relationship.
Choice B: Ensuring the patient's room is tidy is important for the patient's physical comfort but does not directly address emotional support.
Choice C: Keeping the patient's family informed is crucial for communication but may not directly provide emotional support to the patient.
Choice D: Rotating nursing staff may offer varied interactions, but consistency and building rapport with the same caregiver can be more beneficial for emotional support in this context.
A nurse is preparing to administer fluoxetine 40 mg PO daily. The available medication is fluoxetine 20 mg/mL. How many mL should the nurse administer? How many mL of fluoxetine should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: To calculate the mL of fluoxetine to administer, use the formula: desired dose (40 mg) / stock dose (20 mg/mL) = mL to administer. Therefore, 40 mg / 20 mg/mL = 2 mL. This is why choice B (2 mL) is correct. Choice A (1 mL) is incorrect as it does not provide the full dose. Choices C (3 mL) and D (4 mL) are incorrect as they exceed the required dose.