Nokea
For which of the following client outcomes should the nurse administer chlordiazepoxide to a client experiencing acute alcohol withdrawal?
- A. Minimize diaphoresis
- B. Maintain abstinence
- C. Lessen craving
- D. Prevent delirium tremens
Correct Answer: D
Rationale: The correct answer is D: Prevent delirium tremens. Chlordiazepoxide is a benzodiazepine used to manage acute alcohol withdrawal symptoms, including preventing delirium tremens, a severe and potentially life-threatening complication. It helps to stabilize the client's central nervous system by reducing the risk of seizures and severe agitation associated with delirium tremens. Choices A, B, and C are incorrect as chlordiazepoxide's primary role in alcohol withdrawal is not to minimize diaphoresis, maintain abstinence, or lessen craving, but rather to manage the more serious symptoms of withdrawal like delirium tremens.
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Which of the following actions should the nurse take when observing infiltration of fluid into the tissue surrounding an IV insertion site?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct answer is C: Elevate the extremity. Elevating the extremity helps to reduce swelling and minimize further infiltration of fluid into the surrounding tissue. By elevating the extremity, gravity assists in draining the fluid away from the IV site. This action helps to prevent tissue damage and potential complications.
Incorrect choices:
A: Flushing the IV catheter will not address the infiltration and may worsen the situation.
B: Applying pressure to the IV site can further damage the tissue and exacerbate the infiltration.
D: Slowing the infusion rate may not prevent further infiltration and does not address the existing issue effectively.
Which of the following information should the nurse include in the teaching for a school-age child with a new prescription for a fluticasone metered-dose inhaler? (Select all that apply)
- A. Soak the inhaler in water after use
- B. Have your child take one inhalation as needed for shortness of breath
- C. Shake the device prior to administration
- D. A spacer will make it easier to use the device
- E. Rinse your child's mouth following administration
Correct Answer: E
Rationale: The correct answer is E: Rinse your child's mouth following administration. Fluticasone is a corticosteroid inhaler that can cause oral thrush as a side effect. Rinsing the mouth after each use helps prevent this side effect. Choice A is incorrect because soaking the inhaler in water can damage the device. Choice B is incorrect because fluticasone is a maintenance medication, not a rescue inhaler for shortness of breath. Choice C is incorrect because shaking the device is not necessary for a metered-dose inhaler. Choice D is incorrect because while a spacer can help improve inhaler technique, it is not essential for using a metered-dose inhaler.
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift and the client received atenolol instead of allopurinol.Which of the following actions should the nurse take first when discovering a medication error in which atenolol was given instead of allopurinol to a client with gout?
- A. Obtain the client's blood pressure
- B. Contact the client's provider
- C. Inform the charge nurse
- D. Complete an incident report
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to obtain the client's blood pressure (Choice A). This is important because atenolol is a beta-blocker that can lower blood pressure, and giving it to a client with gout instead of allopurinol can potentially result in adverse effects or exacerbate the underlying condition. By obtaining the client's blood pressure, the nurse can assess if there have been any significant changes since the administration of the incorrect medication. This immediate assessment allows the nurse to monitor for any potential adverse effects and take appropriate action if necessary. Contacting the client's provider (Choice B) would be important, but assessing the immediate impact on the client's health by checking the blood pressure takes precedence. Informing the charge nurse (Choice C) and completing an incident report (Choice D) are important steps to take after addressing the immediate health concern of the client.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.
Which of the following medications should the nurse plan to administer to a client who has heroin toxicity, is unresponsive, has pinpoint pupils, and a respiratory rate of 8/min?
- A. Methadone
- B. Naloxone
- C. Diazepam
- D. Bupropion
Correct Answer: B
Rationale: The correct answer is B: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like heroin. In this scenario, the client's symptoms of unresponsiveness, pinpoint pupils, and respiratory depression indicate opioid toxicity. Naloxone will competitively bind to opioid receptors, reversing respiratory depression and potentially restoring consciousness. Methadone (A) is used for opioid dependence but not acute toxicity. Diazepam (C) is a benzodiazepine and not indicated for opioid toxicity. Bupropion (D) is an antidepressant and not appropriate for this situation.