Nokea
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
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After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Inform the pharmacist who dispensed the medication.
- B. Evaluate the client for symptoms of a drug overdose.
- C. Report the medication error to the nursing supervisor.
- D. Review the medication transcription with the nurse.
Correct Answer: B
Rationale: Evaluating for overdose symptoms ensures client safety, addressing potential harm from the error. Informing the pharmacist, reporting, and reviewing transcription are secondary actions.
When triaging emergency room clients, which client should the nurse assess first?
- A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
- B. A female client with severe right lower abdominal pain who is febrile and vomiting.
- C. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating.
- D. A child who has had a cold for two days and now is coughing up green sputum.
Correct Answer: B
Rationale: Severe right lower abdominal pain with fever and vomiting suggests appendicitis, a surgical emergency requiring immediate assessment. Vomiting, leg pain, and green sputum are less urgent conditions.
The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?
- A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill.
- B. Instruct the clients' family members to stay in the visitor waiting area until further notice.
- C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner.
- D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
Correct Answer: D
Rationale: Keeping clients and visitors in rooms with closed doors follows the RACE protocol, containing fire and smoke. Calling the operator, directing to the waiting area, or evacuating may delay safety measures.
The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Teach the client about foods high in fiber.
- C. Administer a prescribed dose of a laxative.
- D. Assist the client in drinking warm prune juice.
Correct Answer: D
Rationale: Assisting with drinking warm prune juice is within the aide's scope and promotes natural relief of constipation. Listening for bowel sounds, teaching about fiber, and administering laxatives require nursing skills and are beyond the aide's role.