Nokea
A patient is rushed to the ER after overdosing on benzodiazepines. The nurse anticipates an order for
- A. lorazepam (Ativan).
- B. flumazenil (Romazicon).
- C. naloxone (Narcan).
- D. alprazolam (Xanax).
Correct Answer: B
Rationale: Flumazenil is the antidote for benzodiazepine overdose, reversing sedation. Lorazepam and alprazolam are benzodiazepines, and naloxone is for opioid overdose.
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Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
- A. Uncompensated respiratory acidosis
- B. Uncompensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
- A. Disturbed body image related to major changes in the structure and function of the larynx
- B. Ineffective airway clearance related to excess mucus in airway, due to surgical procedure
- C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
- D. Impaired verbal communication related to inability to talk, due to removal of larynx
Correct Answer: B
Rationale: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
- A. A diabetic with a foot ulcer
- B. A client with a deep vein thrombosis receiving intravenous heparin
- C. A client being weaned from a tracheostomy
- D. A post-operative cholecystectomy with a T-tube
Correct Answer: A
Rationale: LPNs can manage stable clients with routine care, like a diabetic with a foot ulcer requiring dressings. Heparin, tracheostomy weaning, and T-tube management involve complex assessments better suited for RNs.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.