Nokea
Which of the following medications should the nurse anticipate administering to a client who has taken a large amount of diazepam?
- A. Ondansetron
- B. Magnesium Sulphate
- C. Flumazenil
- D. Protamine Sulphate
Correct Answer: C
Rationale: The correct answer is C: Flumazenil. Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, such as diazepam. It competes with benzodiazepines at the receptor site, reversing their sedative and hypnotic effects. Ondansetron (A) is an antiemetic, Magnesium Sulphate (B) is used for various conditions like pre-eclampsia, Protamine Sulphate (D) is used to reverse heparin anticoagulation. Flumazenil is the most appropriate choice for reversing the effects of diazepam overdose.
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A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client. Nursing Action: Document the blood product transfusion in the client's medical record.
- A. Indicated
- B. Not indicated
Correct Answer: A
Rationale: The correct answer is A: Indicated. Documenting the blood product transfusion in the client's medical record is crucial for legal, ethical, and continuity of care reasons. Documentation ensures that all relevant information about the transfusion is recorded accurately, including the type of blood product, volume infused, patient's vital signs, any adverse reactions, and the healthcare provider's orders. This documentation serves as a permanent record of the procedure, aiding in monitoring the patient's response to the transfusion and facilitating communication among healthcare team members. Failure to document the blood transfusion can lead to serious consequences, such as improper monitoring, increased risk of errors, and compromised patient safety. Therefore, documenting the blood product transfusion in the client's medical record is a vital and necessary nursing action. Other choices are incorrect as they do not address the importance of documentation in ensuring safe and effective patient care.
Which of the following over-the-counter medications should the nurse identify that the client should discontinue when starting lithium?
- A. Aspirin
- B. Ibuprofen
- C. Famotidine
- D. Bisacodyl
Correct Answer: B
Rationale: The correct answer is B: Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase lithium levels and lead to toxicity. NSAIDs compete with lithium for renal excretion, resulting in higher lithium levels. Aspirin (choice A) is not typically contraindicated with lithium. Famotidine (choice C) and Bisacodyl (choice D) do not have significant interactions with lithium.
Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.
Which of the following statements should the nurse include in the teaching about the new medication? Select the 2 statements the nurse should include in the teaching.
- A. You should take medication with dairy products
- B. This medication may cause constipation.
- C. It is common to experience headache or blurred vision while taking this medication.
- D. You should avoid the sun while taking this medication.
Correct Answer: B, D
Rationale: The correct answers are B and D. Statement B is important as it informs the patient about a potential side effect (constipation) of the medication, promoting awareness and preparedness. Statement D is crucial as some medications can increase sensitivity to sunlight, leading to adverse reactions like sunburn. Choices A, C, and the remaining options are incorrect as taking medication with dairy products can interfere with absorption, experiencing headache or blurred vision is not common for all medications, and not all medications require sun avoidance.