Nokea
A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?
- A. Flumazenil
- B. Phytonadione
- C. N-acetylcysteine
- D. Naloxone hydrochloride
Correct Answer: C
Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Flumazenil is the antidote for benzodiazepine reversal. Phytonadione is the antidote for warfarin sodium. Naloxone hydrochloride reverses respiratory depression caused by an opioid.
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The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
- A. Bed rest for 48 hours
- B. Light ambulation as tolerated
- C. Heavy lifting after 24 hours
- D. High-intensity exercise
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
A client with atrial fibrillation is prescribed digoxin (Lanoxin). Which finding indicates a potential toxicity?
- A. Heart rate of 80 bpm.
- B. Visual disturbances.
- C. Blood pressure of 120/80 mm Hg.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence
The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.
- A. Amount of alcohol consumed daily.
- B. Use of antacids.
- C. Dietary intake of fiber.
- D. Use of Vitamin K supplements.
- E. Intake of fruit juices.
Correct Answer: A, B
Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.
What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
- A. Weakness
- B. Constipation
- C. Shortness of breath
- D. Dusky lips and gums
- E. Smooth, sore, red tongue
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.