The healthcare provider prescribes the anticoagulant heparin for a client with a pulmonary embolism. Before initiating the medication, the nurse should ensure that which drug is readily available in case of heparin overdose?
Warfarin.
Vitamin K.
Protamine sulfate.
Diphenhydramine HCI.
The Correct Answer is C
A. Warfarin: Warfarin is an oral anticoagulant used for long-term anticoagulation, but it is not used for reversing the effects of heparin. They are different classes of anticoagulants with distinct reversal agents.
B. Vitamin K: Vitamin K is used to reverse the effects of warfarin, not heparin.
C. Protamine sulfate: Protamine sulfate is the specific antidote for heparin overdose. It neutralizes the effects of heparin and is used to quickly reverse its anticoagulant effects in case of an overdose or excessive bleeding.
D. Diphenhydramine HCl: Diphenhydramine is an antihistamine and has no role in reversing anticoagulants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instruct the client that since the hematocrit remains low, the daily injections are still necessary: A hematocrit of 43% is within the normal range, suggesting the client’s anemia is improving. If the hematocrit were still low, continuing daily injections would be appropriate, but this is not the case here.
B. Notify the healthcare provider of the client’s hematocrit level so the frequency of injections can be reduced: Since the hematocrit is normal, there is no need to notify the healthcare provider specifically for changing the injection frequency based solely on the hematocrit level. Reducing injection frequency should be based on the overall treatment plan and not just the current hematocrit.
C. Advise the client that the medication is having the desired effect, but daily injections will continue to be needed for life for this chronic condition: While the medication may be effective, informing the client about the potential for less frequent injections could improve adherence and reduce discomfort, if the healthcare provider approves.
D. Offer to instruct the client in self-administration techniques to improve the client's sense of control over the painful daily injections: Teaching self-administration can empower the client and potentially reduce discomfort by allowing the client to become more comfortable with the process. It also offers the opportunity for the client to manage their injections more conveniently and with greater control.
Correct Answer is B
Explanation
A. Expresses that they cannot get enough air to breathe: While this is concerning, it is less specific than a respiratory rate finding for opioid overdose.
B. Respiratory rate of 7 breaths/minute: This indicates severe respiratory depression, a critical sign of opioid overdose, which necessitates immediate administration of naloxone.
C. Intercostal retractions and bilateral wheezing on auscultation: These signs suggest respiratory distress but do not directly indicate an opioid overdose.
D. Pulse oximeter reading of 89% on room air: While low, this reading does not specifically indicate opioid overdose unless accompanied by respiratory depression.
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