Nokea
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
- A. Cyanocobalamine
- B. Protamine sulfate
- C. Streptokinase
- D. Sodium warfarin
Correct Answer: B
Rationale: Protamine sulfate neutralizes heparin's anticoagulant effect.
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The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
- A. Diminished femoral pulses
- B. Harlequin's sign
- C. Circumoral pallor
- D. Acrocyanosis
Correct Answer: A
Rationale: Diminished femoral pulses suggest coarctation of the aorta, a cardiac anomaly, requiring further evaluation.
An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?
- A. ineffective coping
- B. activity intolerance
- C. ineffective tissue perfusion
- D. risk for injury
Correct Answer: D
Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
- A. Pieces of hot dog
- B. Carrot sticks
- C. Pieces of cereal
- D. Raisins
Correct Answer: C
Rationale: Cereal pieces are soft, safe, and promote chewing without the choking risk posed by hot dogs, carrots, or sticky raisins in toddlers.
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.