Nokea
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
- A. Immediately stop the infusion.
- B. Discontinue the PCA pump.
- C. Administer naloxone per standing orders.
- D. Administer supplementary oxygen.
- E. File an incident report.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (A), administering naloxone (C) to reverse effects, providing oxygen (D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (B) is not immediate.
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- A. Raisins
- B. Oranges
- C. Apricots
- D. Bananas
Correct Answer: A
Rationale: Raisins are lower in potassium compared to oranges, apricots, and bananas, making them suitable for a low-potassium diet.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.
A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?
- A. Apply direct pressure to the site
- B. Check the pedal pulses on the right leg
- C. Notify the physician
- D. Turn the client to the prone position
Correct Answer: A
Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.