Nokea
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.
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The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:
- A. Seal off the track left by the needle in the tissue.
- B. Speed the spread of the medication in the tissue.
- C. Avoid the discomfort of the needle pulling on the skin.
- D. Prevent organisms from entering the body through the skin puncture.
Correct Answer: A
Rationale: Holding gauze against the injection site prevents medication leakage along the needle track, ensuring proper drug absorption.
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first?
- A. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks' gestation. She is receiving magnesium sulfate @ 2 g\hour. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse's shift report
- B. A 19-year-old 18 weeks' IUP who is now 12 hours post motor vehicle accident with bright red vaginal bleeding
- C. A G8 P4 Ab3 at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa. Two days ago she was admitted with severe bright red vaginal bleeding that has tapered off now
- D. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours
Correct Answer: B
Rationale: The 19-year-old with bright red vaginal bleeding post-accident at 18 weeks is at high risk for miscarriage or placental abruption, requiring immediate assessment. The other clients are stable or less acute.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
Which intervention would you expect to render to the client in a sickle cell anemia crisis?
- A. The administration of a thrombolytic medication
- B. The administration of hydroxyurea
- C. Placing the client in the Trendelenburg position
- D. Placing the client in the lithotomy position
Correct Answer: B
Rationale: Hydroxyurea is used in sickle cell anemia to reduce the frequency of crises by increasing fetal hemoglobin, which helps prevent sickling of red blood cells.
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
- A. Assessment data, biochemical data, clinical data and dietary data
- B. Ancestral cultural data, biochemical data, clinical data and dietary data
- C. Anthropometric data, biological data, chemical data and dietary data
- D. Anthropometric data, biochemical data, clinical data and dietary data
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).