Question

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?

Answer 1

Correct Answers:

Protamine sulfate

Rationale :

🔹 Protamine sulfate is the specific antidote for heparin overdose.

🔹 It binds with heparin to form a stable complex that neutralizes its anticoagulant effect.

🔹 Having the antidote at the bedside is critical in case of hemorrhage.

🔹 Other listed drugs (Vitamin K, acetylcysteine) are used for different conditions.

🔹 Rapid reversal is lifesaving in pulmonary embolism treatment complications.

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Answer 2

Correct Answers:

Place a large-face clock in the client's bedroom.

Rationale :

✅ Clients with Alzheimer’s disease benefit from reorientation aids.

✅ A large-face clock helps maintain orientation to time.

✅ It reduces confusion and anxiety.

✅ Environmental cues promote cognitive stability.

✅ Night lighting instead of dark rooms prevents agitation at night.

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Answer 3

Correct Answers:

Thrombocytopenia

Rationale :

🔷 Heparin therapy is contraindicated in patients with low platelet counts.

🔷 It increases the risk of severe bleeding.

🔷 Platelets are necessary for clotting function.

🔷 Alternative anticoagulants may be chosen when thrombocytopenia exists.

🔷 Reporting this risk prevents life-threatening hemorrhage.

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Answer 4

Correct Answers:

Allow the client to sign the consent with an X.

Rationale :

💎 A client who understands but cannot write can sign with an X, witnessed.

💎 The signature remains legally binding.

💎 The nurse ensures informed consent is present.

💎 Capacity to understand is more important than writing ability.

💎 It protects both patient rights and legal standards.

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Answer 5

Correct Answers:

Apply compression stockings to the lower extremities.

Rationale :

♦ Postoperative clients are at risk of DVT due to immobility.

♦ Compression stockings enhance venous return.

♦ Prevents venous stasis and clot formation.

♦ Safe alternative to anticoagulants when contraindicated.

♦ Encouraging mobility and stockings reduces PE risk.

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Answer 6

Correct Answers:

Latex

Rationale :

🌟 Clients allergic to bananas, avocados, chestnuts, or kiwis are at risk for latex allergy.

🌟 This is due to cross-reactivity of proteins.

🌟 Latex is used in many surgical and nursing supplies.

🌟 Precaution avoids life-threatening anaphylaxis.

🌟 Non-latex equipment should be used for these clients.

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Answer 7

Correct Answers:

Intense pain with movement

Rationale :

❖ Compartment syndrome is marked by severe pain unrelieved by opioids.

❖ Early recognition is vital to prevent ischemia and necrosis.

❖ Other signs include paresthesia, pallor, pulselessness, paralysis.

❖ Pain with passive movement is the earliest reliable sign.

❖ Requires urgent surgical fasciotomy if confirmed.

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Answer 8

Correct Answers:

Vigorously strip the chest tube twice daily.

Rationale :

⬖ Stripping chest tubes creates dangerous negative pressure.

⬖ It may damage lung tissue or cause collapse.

⬖ Proper management is milking only if ordered.

⬖ Tidaling and bubbling monitoring are safe practices.

⬖ Clarifying unsafe orders ensures client safety.

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Answer 9

Correct Answers:

Calcium level 11.5 mg/dl

Rationale :

🔶 Normal calcium is 8.5–10.5 mg/dL.

🔶 Hypercalcemia suggests metabolic imbalance from TPN.

🔶 It can cause arrhythmias, weakness, kidney stones.

🔶 Electrolytes must be monitored regularly with TPN therapy.

🔶 Prompt reporting prevents serious complications.

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Answer 10

Correct Answers:

Decreased blood pressure

Rationale :

🔴 Valsartan is an ARB used for heart failure and hypertension.

🔴 Effectiveness is shown by lower blood pressure and improved symptoms.

🔴 It decreases afterload and workload of the heart.

🔴 Improves cardiac output and perfusion.

🔴 Monitoring blood pressure validates therapeutic response.

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RN Adult Medical Surgical 2019 Exam 4

No.

1 :
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?

2 :
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

3 :
A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

4 :
A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

5 :
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

6 :
A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

7 :
A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

8 :
A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider.

9 :
A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

10 :
A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an Indication that the medication is effective?

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RN Adult Medical Surgical 2019 Exam 4

No.

1 : 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?

2 : A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

3 : A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

4 : A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

5 : A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

6 : A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

7 : A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

8 : A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider.

9 : A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

10 : A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an Indication that the medication is effective?

1 :
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?

2 :
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

3 :
A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

4 :
A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

5 :
A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

6 :
A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances?

7 :
A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?

8 :
A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider.

9 :
A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

10 :
A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an Indication that the medication is effective?