Nokea
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
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A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.
A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles in lungs
- B. Decreased thirst
- C. Poor skin turgor
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart's inability to pump effectively leads to fluid accumulation in the lungs, causing crackles on auscultation. Decreased thirst (B) is not a typical manifestation. Poor skin turgor (C) is more indicative of dehydration. Tachycardia (D) may occur but is not specific to heart failure.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. You should consider taking a sleeping pill before bed each night.'
- B. It is always difficult caring for someone who is terminally ill.'
- C. I am sure you're doing a great job taking care of your mother.'
- D. I can give you information about respite care if you are interested.'
Correct Answer: D
Rationale: The correct response is D: "I can give you information about respite care if you are interested." This is the best response because it addresses the son's lack of sleep, which is a common issue for family caregivers. Offering information about respite care can provide the son with the opportunity to take a break and get some rest while ensuring his mother's needs are still met. It shows empathy and support for his situation.
Choice A is incorrect because suggesting a sleeping pill does not address the underlying issue of caregiver stress and may not be the best solution. Choice B is incorrect as it is a general statement and does not offer any practical help or support. Choice C, while supportive, does not provide a solution to the son's lack of sleep.
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
- A. Tell me what concerns you have about using a bed pan.'
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.'
- C. I will have the physical therapist ambulate you to the bathroom.'
- D. You have to use the bed pan for your own safety.'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest. Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case. Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.