A nurse receives her client back from the operating room and observes fresh blood on the sheets. The nurse realizes that the client's incision is bleeding and documentation shows that the client received a double dose of intravenous heparin in the operating room. What action should the nurse take?
Administer protamine sulfate
Transfuse platelets.
Transfuse packed red blood cells.
Administer vitamin K.
The Correct Answer is A
A. Administer protamine sulfate: Protamine sulfate is the specific antidote for heparin. It binds to heparin and neutralizes its anticoagulant effect, making it the most appropriate intervention to control active bleeding due to a heparin overdose. Rapid administration is critical to prevent further blood loss.
B. Transfuse platelets: Platelet transfusion is generally indicated for thrombocytopenia or platelet dysfunction, not for anticoagulation caused by heparin. Heparin-induced bleeding is due to inhibited clotting, not platelet deficiency.
C. Transfuse packed red blood cells: Packed red blood cells may be required if the client experiences significant blood loss, but they do not address the underlying anticoagulation caused by the heparin overdose. This intervention is supportive, not corrective.
D. Administer vitamin K: Vitamin K is the antidote for warfarin or vitamin K–dependent anticoagulant toxicity. It has no effect on heparin-induced anticoagulation and would not stop the bleeding in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Improved mood: Montelukast is a leukotriene receptor antagonist used to manage asthma and allergic rhinitis. While mood changes have been reported as rare adverse effects, improvement in mood is not an indicator of therapeutic effectiveness.
B. Increased bronchodilation: Montelukast does not act as a direct bronchodilator. Its mechanism involves blocking leukotrienes to reduce inflammation and prevent bronchoconstriction, so immediate bronchodilation is not expected.
C. Reduced airflow: Reduced airflow indicates worsening airway obstruction, which suggests the drug is not achieving its intended therapeutic effect and may signal uncontrolled asthma.
D. Decreased wheezing: A decrease in wheezing reflects reduced airway inflammation and bronchoconstriction, indicating that montelukast is effectively managing the client’s asthma symptoms and improving respiratory function.
Correct Answer is C
Explanation
A. Seizure: Seizures are not a common manifestation of hydralazine toxicity. While severe hypotension could contribute to CNS symptoms, seizures are not a typical or expected clinical finding with this medication.
B. Hypertension: Hydralazine is a direct vasodilator used to lower blood pressure. Hypertension is not associated with hydralazine toxicity; instead, excessive hypotension may occur if the drug effect is too strong.
C. Tachycardia: Tachycardia is a common clinical finding associated with hydralazine toxicity. The vasodilation caused by hydralazine can lead to reflex sympathetic stimulation, resulting in an increased heart rate as the body attempts to maintain cardiac output and blood pressure.
D. Constipation: Constipation is not related to hydralazine use or toxicity. This adverse effect is not expected and does not indicate toxicity from the medication.
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