Nursing Elites

1. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?

• A. Protamine
• B. Amicar
• C. Imferon
• D. Diltiazem

Correct answer: A

Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).

2. A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?

• A. Determine the client's usual pattern of activity.
• B. Assist the client in developing a healthy eating plan.
• C. Encourage the client to join a support group.
• D. Provide the client with a list of signs and symptoms to report to the provider.

Correct answer: A

Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.

3. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?

• A. I use a sliding scale to adjust regular insulin to my sugar level.
• B. Since my eyesight is so bad, I ask the nurse to fill several syringes.
• C. I keep my regular insulin bottle in the refrigerator.
• D. I always make sure to shake the NPH bottle hard to mix it well.

Correct answer: D

Rationale: Shaking the NPH insulin bottle hard can cause air bubbles and affect dosing accuracy; it should be rolled gently instead.

4. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

• A. Sedative hypnotics are effective analgesics
• B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
• C. Caffeine beverages can increase the effect of sedative hypnotics
• D. Avoidance of excessive exercise and high temperature is recommended

Correct answer: B

Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.

5. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain a sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw the catheter in a circular motion

Correct answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

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