A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?

"I will give you some ice chips instead of a drink of water".

"I have to assess your gag reflex before giving you any food or water".

"I will call the primary health care provider and request an order for food and water".

"Let's try having a small sip of water to see if you can swallow".

Answer and Explanation

The Correct Answer is B

A.   Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B.   Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C.   Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D.   This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.

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Correct Answer is B

Explanation

A. Deferasirox is a medication used to treat chronic iron overload due to blood transfusions. It is not used as an antidote for heparin.
B. Protamine sulfate is the antidote for heparin. It works by binding to heparin, neutralizing its anticoagulant effects. Protamine sulfate is typically used in cases of heparin overdose or when rapid reversal of heparin's effects is necessary, such as during surgery or if there is active bleeding.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose due to its ability to replenish glutathione stores in the liver and protect against liver damage. It has no role in reversing heparin's effects.
D. Vitamin K is the antidote for warfarin, not heparin. It promotes the synthesis of clotting factors in the liver that are inhibited by warfarin, thus reversing its anticoagulant effects.

A. Use IV tubing specific for heparin sodium when administering the infusion. B. Administer 50,000 units of heparin by IV bolus every 12 hr. C. Have vitamin K available on the nursing unit. D. Check the activated partial thromboplastin time (aPTT) every 4 hr.

Correct Answer is D

Explanation

A. Heparin should be administered using IV tubing that is specifically labeled for heparin or that has been dedicated for anticoagulant use only. However, this is not the most important action.

B. Heparin is not typically administered as a bolus (large single dose) because of its rapid onset of action and potential for causing bleeding complications. Instead, heparin is usually administered as a continuous IV infusion to achieve and maintain therapeutic anticoagulation.
C. While vitamin K is an antidote for reversing the effects of warfarin (a different type of anticoagulant), it is not used for reversing the effects of heparin. The reversal agent for heparin is protamine sulfate. Therefore, having vitamin K available is not necessary for managing a client receiving heparin.
D. The aPTT is a laboratory test used to monitor the therapeutic effect of heparin therapy. It measures the clotting time of blood and helps ensure that the client's heparin infusion is within the desired therapeutic range. Checking aPTT regularly (usually every 4-6 hours initially, then adjusting based on results) is essential to maintain therapeutic anticoagulation and avoid complications like bleeding or clotting.

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A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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