Nokea
Which assessment would the nurse obtain before administering an anticoagulant to a client with DVT? Select all that apply.
- A. Test for a positive Homans' sign.
- B. Examine extremity for skin temperature.
- C. Assess pain.
- D. Assess blood pressure.
- E. Check for pedal pulse.
Correct Answer: A,B,C,E
Rationale: Preadministration assessment for a client with a DVT should include checking for a pedal pulse, examining the extremity for color and skin temperature, assessing for pain, and checking for a positive Homans' sign.
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A client is experiencing an overdosage of heparin. The nurse would expect to administer which of the following?
- A. Vitamin K1
- B. Protamine
- C. Ticlopidine
- D. Tenecteplase
Correct Answer: B
Rationale: Heparin overdosage is treated with protamine, which neutralizes heparin's anticoagulant effects.
A client is receiving streptokinase. The nurse understands that which of the following would occur? Select all that apply.
- A. Breakdown of existing thrombi
- B. Reopening of occluded blood vessels
- C. Prevention of tissue necrosis
- D. Decreased risk of internal bleeding
- E. Prevention of formation of a thrombus
Correct Answer: A,B,C
Rationale: Streptokinase is a thrombolytic drug. Thrombolytic drugs break down existing thrombi, reopen blood vessels after occlusion, and prevent tissue necrosis.
When teaching a class about parenterally administered heparin, which of the following would the nurse include? Select all that apply.
- A. Onset of action is almost immediate.
- B. Maximum effect occurs within 10 minutes.
- C. It is preferably given intramuscularly.
- D. Clotting time returns to normal within 4 hours.
- E. It causes fewer adverse reactions than the oral form.
Correct Answer: A,B,D
Rationale: Parenteral heparin results in an almost immediate onset of action with a maximum effect within 10 minutes, but clotting returns to normal within 4 hours unless subsequent doses are given. It is preferably given subcutaneously or intravenously.
A client in a health care facility is receiving the thrombolytic drug reteplase. Which nursing diagnosis would be most likely?
- A. Anxiety
- B. Constipation
- C. Disturbed Sensory Perception
- D. Ineffective Tissue Perfusion
Correct Answer: A
Rationale: The nursing diagnoses for a client receiving the thrombolytic drug reteplase should include Anxiety, as thrombolytic therapy can be stressful due to its critical nature.
Protamine is used to treat overdose of which of the following medications? Select all that apply.
- A. Clopidogrel (Plavix)
- B. Heparin
- C. Enoxaparin (Lovenox)
- D. Alreplase (Activase)
- E. Warfarin (Coumadin)
Correct Answer: B,C
Rationale: Protamine is used to treat overdose of heparin and low-molecular-weight heparins (LMWHs).