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A nurse is caring for a client who has respiratory depression from an opioid administration.
After administering naloxone, which finding should the nurse expect?
- A. Somnolence
- B. Increased respiratory rate
- C. Sudden onset of pain or discomfort
- D. Hypertension and tachycardia
- E. Nausea and vomiting
Correct Answer: B
Rationale: After administering naloxone, the nurse should expect an increased respiratory rate. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. By blocking opioid receptors, naloxone can restore normal breathing patterns. Choices A (Somnolence), C (Sudden onset of pain or discomfort), D (Hypertension and tachycardia), and E (Nausea and vomiting) are incorrect because they are not typical findings after administering naloxone. Somnolence would not be expected as naloxone counteracts sedation caused by opioids. Sudden onset of pain or discomfort is unrelated to naloxone administration. Hypertension and tachycardia are more indicative of opioid overdose, which naloxone would mitigate. Nausea and vomiting are also not common side effects of naloxone.
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A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Zinc
- B. Calcium
- C. Folate
- D. Iron
Correct Answer: C
Rationale: The correct answer is C: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the development of the baby's brain and spinal cord. Zinc (A) is important for overall health but not specifically for preventing neural tube defects. Calcium (B) is crucial for bone health, not neural tube development. Iron (D) is vital for preventing anemia but not directly related to neural tube defects.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.
Which of the following interventions should the nurse include in the teaching?
- A. Drink 2 liters of warm water per day.
- B. Wipe from back to front after urination.
- C. Urinate immediately after sexual intercourse.
- D. Limit fluid intake to prevent frequent urination.
Correct Answer: C
Rationale: The correct answer is C: Urinate immediately after sexual intercourse. This intervention helps prevent urinary tract infections by flushing out bacteria that may have entered the urethra during intercourse. It is important to teach this to promote urinary tract health.
A: Drinking 2 liters of warm water per day is generally good for hydration but not directly related to preventing UTIs.
B: Wiping from back to front can actually introduce bacteria from the rectal area to the urethra, increasing the risk of UTIs.
D: Limiting fluid intake to prevent frequent urination is not recommended as it can lead to dehydration and concentration of urine, potentially worsening UTIs.
A nurse is caring for a client who asks for information regarding organ donation.
Which statement should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. You have the right to change your decision about organ donation at any time.
- C. Discussing your wishes with your family can help ensure they are honored.
- D. Organ donation does not delay funeral arrangements or affect body appearance.
- E. Medical care provided before death will not be affected by your organ donor status.
Correct Answer: E
Rationale: The correct answer is E because it addresses a common misconception. Organ donor status does not affect medical care provided before death. Choice A is incorrect as organ donor consent can also be verbal. Choice B is incorrect because changing one's decision about organ donation may not always be feasible in emergency situations. Choice C is incorrect as discussing wishes with family does not guarantee they will be honored legally. Choice D is incorrect as organ donation may have some impact on funeral arrangements and body appearance.
A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter.
Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.