Page 1804 - Saunders Comprehensive Review For NCLEX-RN

While implementing this prescription, the nurse ensures that which
medication is available on the nursing unit?
1. Vitamin K
2. Protamine sulfate
3. Potassium chloride
4. Aminocaproic acid
638. A client receiving thrombolytic therapy with a continuous infusion of
alteplase suddenly becomes extremely anxious and reports itching. The
nurse hears stridor and notes generalized urticaria and hypotension. Which
interventions should the nurse anticipate? Select all that apply.
1. Stop the infusion.

2. Raise the head of the bed.

3. Administer protamine sulfate.
4. Administer diphenhydramine.

5. Call for the Rapid Response Team (RRT).

639. The nurse should report which assessment finding to the primary health care
provider (PHCP) before initiating thrombolytic therapy in a client with
pulmonary embolism?
1. Adventitious breath sounds
2. Temperature of 99.4° F (37.4° C) orally
3. Blood pressure of 198/110 mm Hg
4. Respiratory rate of 28 breaths per minute
640. The nurse provides instructions to the client about nicotinic acid prescribed
for hyperlipidemia. Which statement by the client indicates understanding of
the instructions?
1. “The medication should be taken with meals to decrease
flushing.”
2. “It is not necessary to avoid the use of alcohol when taking
nicotinic acid.”
3. “Clay-colored stools are a common side effect and should not be
of concern.”
4. “Ibuprofen taken 30 minutes before the nicotinic acid may
decrease the flushing.”

Answers

625. Answer: 3

Rationale: Common laboratory ranges for activated partial thromboplastin time
(aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal
value, the client’s aPTT would be considered therapeutic if it was 60 seconds.
Prothrombin time assesses response to warfarin therapy.
Test-Taking Strategy: Focus on the subject, the therapeutic effect of heparin.
Prothrombin time is eliminated because it assesses response to warfarin therapy. The

1804