Nokea
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/50 mmHg. Which of the following medications should the nurse administer?
- A. Naloxone
- B. Promethazine
- C. Acetylcysteine
- D. Flumazenil
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like morphine, which can cause respiratory depression leading to bradypnea (slow breathing) and hypotension. In this case, the client's low respiratory rate and blood pressure indicate opioid overdose. Administering naloxone can help reverse the respiratory depression and stabilize the client's breathing and blood pressure.
Promethazine (B) is an antihistamine used for nausea and vomiting, not for opioid overdose. Acetylcysteine (C) is a mucolytic agent used for acetaminophen overdose. Flumazenil (D) is a benzodiazepine antagonist, not indicated for opioid overdose.
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A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.