Question

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

Answer 1

Correct Answers:

Protamine sulfate

Rationale :

💎 Protamine sulfate is the antidote for heparin toxicity. It binds to heparin and neutralizes its anticoagulant effect, preventing excessive bleeding.

💎 The nurse should keep protamine sulfate readily available whenever a client is on continuous heparin infusion to reverse overdose or bleeding complications.

💎 The dosage is typically 1 mg of protamine per 100 units of heparin administered, depending on timing since the last dose.

💎 Close monitoring of aPTT levels and bleeding signs should follow administration.

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Answer 2

Correct Answers:

Continue to monitor the client's respiratory status.

Rationale :

🔷 Slow, steady bubbling in the suction control chamber indicates that suction is functioning properly in a chest drainage system.

🔷 The nurse should not clamp the chest tube or check for leaks, as this bubbling is expected.

🔷 The priority is to continue monitoring the client’s respiratory effort, breath sounds, and oxygen saturation to detect any signs of distress or pneumothorax.

🔷 Only intermittent bubbling in the water-seal chamber indicates air leaks, not in the suction control chamber.

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Answer 3

Correct Answers:

Limit visitors to healthy adults.

Rationale :

🟢 A client with ANC < 1,000/mm³ is considered to have neutropenia, placing them at high risk for infection.

🟢 Restricting visitors to only healthy individuals helps minimize exposure to infectious agents.

🟢 The nurse should also avoid raw fruits, vegetables, and fresh flowers, as they harbor microorganisms.

🟢 Frequent hand hygiene and a private room with protective precautions are recommended.

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Answer 4

Correct Answers:

Encouraging the client to drink 2 to 3 L of water daily

Rationale :

🔶 Clients with COPD often have thick, tenacious secretions that are difficult to expectorate.

🔶 Adequate hydration (2–3 L/day) helps thin bronchial secretions, making coughing more productive.

🔶 This improves airway clearance and oxygenation, reducing the risk of infection.

🔶 Fluids should be spaced throughout the day unless contraindicated by cardiac or renal conditions.

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Answer 5

Correct Answers:

Withhold food and liquids until the client's gag reflex returns.

Rationale :

🔴 After a bronchoscopy, the throat and airway are anesthetized to prevent coughing or gagging during the procedure.

🔴 The nurse must withhold oral intake until the gag and swallow reflexes return to prevent aspiration.

🔴 The return of reflexes can be assessed by gently touching the back of the throat with a tongue depressor or observing the client swallow.

🔴 Monitoring for laryngeal edema, bleeding, and respiratory distress is also essential post-procedure.

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Answer 6

Correct Answers:

Bleeding

Rationale :

💎 A child with leukemia and a low platelet count (thrombocytopenia) is at high risk for spontaneous bleeding.

💎 The nurse should initiate bleeding precautions, including using a soft toothbrush, avoiding intramuscular injections, limiting venipunctures, and preventing falls or injuries.

💎 Monitoring for petechiae, ecchymosis, and hematuria is essential.

💎 These measures help minimize bleeding complications and ensure safe care during critical thrombocytopenia.

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Answer 7

Correct Answers:

Avoid crowds,

Rationale :

🔷 Clients with neutropenia have an impaired immune system due to reduced neutrophil count, which increases infection risk.

🔷 Avoiding crowded places and contact with people who are sick reduces exposure to pathogens.

🔷 They should also practice strict hand hygiene and avoid raw fruits or vegetables that can carry bacteria.

🔷 Daily temperature monitoring, not weekly, helps detect infection early.

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Answer 8

Correct Answers:

Arterial blood gases

Rationale :

🟢 After a thoracotomy and lobectomy, the highest priority is ensuring adequate oxygenation and ventilation.

🟢 Monitoring ABG results provides immediate information about the client’s oxygenation status and acid-base balance.

🟢 Hypoventilation or respiratory distress can occur due to pain, anesthesia, or lung resection.

🟢 While chest drainage, pain, and urine output are important, airway and breathing always take precedence.

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Answer 9

Correct Answers:

WBC 2300/mm3

Rationale :

🔶 A WBC count below 4,000/mm³ indicates leukopenia, often caused by chemotherapy.

🔶 This finding increases the client’s risk for infection and should be reported immediately.

🔶 The nurse should initiate neutropenic precautions, including isolation, strict handwashing, and avoiding invasive procedures when possible.

🔶 Monitoring for fever and signs of infection is critical since these clients may have minimal inflammatory response.

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Answer 10

Correct Answers:

Seizures

Rationale :

🔴 In a client with brain cancer receiving radiation, seizures indicate potential increased intracranial pressure or cerebral edema.

🔴 This is a neurological emergency requiring immediate intervention to prevent brain herniation or further neuronal damage.

🔴 The nurse should assess airway, oxygenation, and prepare for administration of anticonvulsants or corticosteroids as prescribed.

🔴 Other symptoms like chest pain or edema are important but not immediately life-threatening in this context.

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Custom- NUR 211 Final Assessment- Fall 1 2025

No.

1 :
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

2 :
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which Of the following actions should the nurse take?

3 :
A nurse is planning care for a client Who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which Of the following interventions should the nurse include in the plan?

5 :
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

6 :
A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

7 :
A nurse is providing teaching to a client Who has neutropenia. Which Of the following information should the nurse include in the teaching?

8 :
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

9 :
A nurse is reviewing the CBC findings for a female client Who is receiving combination chemotherapy for breast cancer. Which Of the following findings should the nurse report to the provider?

10 :
A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

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Custom- NUR 211 Final Assessment- Fall 1 2025

No.

1 : 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

2 : A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which Of the following actions should the nurse take?

3 : A nurse is planning care for a client Who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which Of the following interventions should the nurse include in the plan?

5 : A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

6 : A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

7 : A nurse is providing teaching to a client Who has neutropenia. Which Of the following information should the nurse include in the teaching?

8 : A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

9 : A nurse is reviewing the CBC findings for a female client Who is receiving combination chemotherapy for breast cancer. Which Of the following findings should the nurse report to the provider?

10 : A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

1 :
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

2 :
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which Of the following actions should the nurse take?

3 :
A nurse is planning care for a client Who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which Of the following interventions should the nurse include in the plan?

5 :
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

6 :
A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

7 :
A nurse is providing teaching to a client Who has neutropenia. Which Of the following information should the nurse include in the teaching?

8 :
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

9 :
A nurse is reviewing the CBC findings for a female client Who is receiving combination chemotherapy for breast cancer. Which Of the following findings should the nurse report to the provider?

10 :
A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?