Nokea
A nurse is working in an endoscopy recovery area. Many of the clients are administered midazolam (Versed) to provide conscious sedation. Which medication is important to have available as an antidote for Versed?
- A. Diazepam (Valium)
- B. Naloxone (Narcan)
- C. Flumazenil (Romazicon)
- D. Florinef (Fludrocortisone)
Correct Answer: C
Rationale: Flumazenil (Romazicon) is the antidote for benzodiazepines like midazolam, reversing sedation or overdose. Naloxone is for opioids, and the others are unrelated.
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A.ls with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
- A. Treat iron-deficiency anemia caused by chemotherapeutic agents
- B. Create a synergistic effect that shortens treatment time
- C. Increase the number of circulating neutrophils
- D. Reverse drug toxicity and prevent tissue damage
Correct Answer: D
Rationale: Leucovorin calcium is given as a rescue therapy to reverse the toxic effects of trimetrexate, protecting healthy cells from damage.
While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor
- B. Avoid sun exposure while using the herbal
- C. Purchase only those brands with FDA approval
- D. Increase daily intake of vitamin E
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by affecting platelet function, so clients should report signs of bruising or bleeding to their physician.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.
The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by:
- A. Taking a warm shower upon awakening
- B. Applying ice packs to the joints
- C. Taking two aspirin before going to bed
- D. Going for an early morning walk
Correct Answer: A
Rationale: A warm shower reduces morning stiffness in rheumatoid arthritis by improving joint mobility and reducing inflammation.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.