Nokea
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.
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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.
How many mL/h should the nurse set the IV infusion pump to deliver half the total volume of lactated Ringer's (4,080 mL) in the first 8 hours?
- A. 200 mL/h
- B. 225 mL/h
- C. 250 mL/h
- D. 255 mL/h
- E. 275 mL/h
Correct Answer: D
Rationale: The correct answer is D: 255 mL/h. To deliver half of 4,080 mL in 8 hours, you need to administer 2,040 mL in 8 hours. To calculate the infusion rate, divide the total volume by the total time: 2,040 mL ÷ 8 hours = 255 mL/h. This rate ensures half of the total volume is infused within the specified time frame.
Choice A (200 mL/h) is too slow, as it would not deliver half the volume in 8 hours. Choices B, C, and E exceed the required rate and would deliver more than half the volume in 8 hours.
A nurse is teaching a client about the prescribed medication. Which of the following statements should the nurse include when teaching the client about the prescribed medication? Select all that apply.
- A. The medication can cause nausea
- B. so take with a meal.
- C. You can experience vivid nightmares.
- D. You may notice your urine becomes lighter in color.
- E. Consumption of a high-protein meal can reduce the effectiveness of the medication.
- F. You may initially notice an increase in involuntary movements.
- G. This medication can make you light-headed if you stand up too quickly from a seated or lying position.
Correct Answer: A, B, E,F
Rationale: The correct statements to include when teaching the client about the prescribed medication are A, B, E, and F. Statement A is important to mention as it informs the client about a potential side effect (nausea) of the medication. Statement B is crucial as taking the medication with a meal can help reduce the likelihood of nausea occurring. Statement E is relevant because high-protein meals can indeed interfere with the medication's effectiveness, so the client should be aware of this. Statement F is crucial as it prepares the client for a possible side effect of an increase in involuntary movements. These statements are important for the client to understand to ensure safe and effective medication use. Statements C, D, and G are incorrect as they do not pertain to the medication's side effects, interactions, or administration, making them irrelevant in this context.
For which of the following adverse effects should the nurse monitor a client who is prescribed metoclopramide following bowel surgery?
- A. Muscle weakness
- B. Sedation
- C. Tinnitus
- D. Peripheral edema
Correct Answer: B
Rationale: The correct answer is B: Sedation. Metoclopramide is a medication that can cause sedation as a side effect. After bowel surgery, sedation can mask signs of postoperative complications such as abdominal pain or changes in vital signs. Muscle weakness (A), tinnitus (C), and peripheral edema (D) are not common adverse effects of metoclopramide and would not typically be monitored for in this situation. Sedation is the most relevant adverse effect to monitor for in a client post-bowel surgery, as it can impact the assessment and management of their recovery.
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.