Nokea
The nurse is caring for a client who is receiving heparin. What drug should be readily available?
- A. Vitamin K
- B. Caffeine
- C. Calcium gluconate
- D. Protamine sulfate
Correct Answer: D
Rationale: The antidote for heparin is protamine sulfate. Vitamin K is the antidote for warfarin. Calcium gluconate is used for magnesium sulfate overdose. Caffeine is a stimulant and not an antidote.
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Based on the client's complaint, the nurse would expect the pain to have which possible effect on the vital signs?
- A. Temperature may be elevated.
- B. Pulse rate may become rapid.
- C. Respiratory rate may slow.
- D. Blood pressure may fall.
Correct Answer: B
Rationale: Acute pain activates the sympathetic nervous system, increasing pulse rate due to stress response.
A 72-year-old man had a total hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan's sign. Which of the following will be included in the initial care of this man?
- A. Warm packs to the left leg
- B. Vigorous massage of the left leg
- C. Placing the left leg in a dependent position
- D. Performing range of motion exercises to the left leg
Correct Answer: C
Rationale: Placing the leg in a dependent position promotes venous return and reduces swelling in suspected deep vein thrombosis. Warm packs, massage, or range of motion may dislodge a clot, increasing embolism risk.
During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
- A. Administer a radioisotope as ordered.
- B. Give the client a cleansing enema.
- C. Locate and mark peripheral pulses.
- D. Encourage high fluid intake before the test.
Correct Answer: C
Rationale: Locating and marking peripheral pulses before cardiac catheterization allows for post-procedure comparison to detect complications like arterial occlusion. Radioisotopes, enemas, and high fluid intake are not standard preparations for this procedure.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.