A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?
Protamine sulfate
Acetylcysteine
Vitamin K
Flumazenil
The Correct Answer is A
Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
Correct Answer is B
Explanation
The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.
The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.
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