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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When auscultating the client's heart and breath sounds during a routine shift assessment, which action by the nurse is most appropriate?
- A. Asking the client to hold the breath
- B. Using the bell of the stethoscope
- C. Positioning the client flat in bed
- D. Locating the xiphoid process
Correct Answer: B
Rationale: The bell of the stethoscope is best for low-pitched heart sounds in pericarditis.
Please indicate with an X the best anatomic area for the nurse to auscultate mitral valve sounds.
- A. Apex of the heart
- B. Second right intercostal space
- C. Second left intercostal space
- D. Lower left sternal border
Correct Answer: A
Rationale: Mitral valve sounds are best heard at the apex (fifth intercostal space, midclavicular line).
The client tells the nurse of being extremely frightened. What is the most appropriate action for the nurse to take at this time?
- A. Stay with the client.
- B. Explain the procedures.
- C. Tell the client it will be fine.
- D. Record the collected data.
Correct Answer: A
Rationale: Staying with the client provides emotional support, reducing fear during a crisis.
Which statement is the best indication that the client understands the surgical procedure involving mitral valve replacement?
- A. My blood will be circulated through a heart-lung machine.
- B. The surgeon will enlarge my valve by inserting a stent.
- C. My blood will be opened during surgery, but my heart will not.
- D. A piece of my leg vein will be used to replace the diseased valve.
Correct Answer: A
Rationale: Mitral valve replacement requires a heart-lung machine for cardiopulmonary bypass.
The nurse checking the client's leg incision is aware that which is the most common blood vessel used in CABG surgery?
- A. The saphenous vein
- B. The femoral artery
- C. The popliteal vein
- D. The iliac artery
Correct Answer: A
Rationale: The saphenous vein is commonly used in CABG due to its accessibility and suitability for grafting.