Page 1810 - Saunders Comprehensive Review For NCLEX-RN

637. Answer: 2

Rationale: The antidote to heparin is protamine sulfate; it should be readily
available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an
antidote for warfarin sodium. Potassium chloride is administered for a potassium
deficit. Aminocaproic acid is the antidote for thrombolytic therapy.
Test-Taking Strategy: Focus on the subject, the antidote for heparin. Knowledge
regarding the various antidotes is needed to answer this question. Remember that
the antidote to heparin is protamine sulfate.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Pharmacology: Cardiovascular Medications: Anticoagulants
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clotting; Safety
Reference: Gahart, Nazareno (2015), p. 626.

638. Answer: 1, 4, 5

Rationale: The client is experiencing an anaphylactic reaction. Therefore, the
priority action is to stop the infusion and notify the RRT. The client may be treated
with antihistamines. Raising the head of the bed would not be helpful, as that may
exacerbate the hypotension. Protamine sulfate is the antidote for heparin, so it is not
useful for a client receiving alteplase.
Test-Taking Strategy: Note the strategic word, priority. Recall that an allergic
reaction and possible anaphylaxis are risks associated with alteplase therapy. Also,
focusing on the signs and symptoms in the question will assist in answering
correctly. When a severe allergic reaction occurs, the offending substance should be
stopped, and lifesaving treatment should begin.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Shock
Health Problem: Adult Health: Cardiovascular: Shock
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Ignatavicius, Workman (2016), pp. 352-353, 607, 939.

639. Answer: 3

Rationale: Thrombolytic therapy is contraindicated in severe uncontrolled
hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would
report the results of the blood pressure to the PHCP before initiating therapy.
Test-Taking Strategy: Focus on the subject, a contraindication for the use of
thrombolytic therapy. Adventitious breath sounds, temperature of 99.4° F (37.4° C),
and respiratory rate of 28 breaths per minute may be present in the client with
pulmonary embolism but are not necessarily signs that warrant reporting before
thrombolytic therapy is initiated.

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