Nokea
A 42-year-old man with metastatic lung cancer is admitted to the hospital. His orders include: do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses him, his BP is 86/50, respirations are 8, and he is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV, is ordered STAT. In planning care for this man, it is IMPORTANT for the nurse to know that
- A. the BP and respirations will need to increase before a second dose of Narcan can be given.
- B. Narcan should not be given to the man because of his DNR status.
- C. a dose of Narcan may need to be repeated in 2-3 minutes.
- D. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.
Correct Answer: C
Rationale: half-life of Narcan is short; may go back into respiratory depression; may need to be repeated
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An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important