Nokea
For which of the following client outcomes should the nurse administer chlordiazepoxide to a client experiencing acute alcohol withdrawal?
- A. Minimize diaphoresis
- B. Maintain abstinence
- C. Lessen craving
- D. Prevent delirium tremens
Correct Answer: D
Rationale: The correct answer is D: Prevent delirium tremens. Chlordiazepoxide is a benzodiazepine used to manage acute alcohol withdrawal symptoms, including preventing delirium tremens, a severe and potentially life-threatening complication. It helps to stabilize the client's central nervous system by reducing the risk of seizures and severe agitation associated with delirium tremens. Choices A, B, and C are incorrect as chlordiazepoxide's primary role in alcohol withdrawal is not to minimize diaphoresis, maintain abstinence, or lessen craving, but rather to manage the more serious symptoms of withdrawal like delirium tremens.
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Which of the following findings is the best indication that morphine has been effective?
- A. The client's vital signs are within normal limits
- B. The client has not requested additional medication
- C. The client is sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension, and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. When a client exhibits symptoms of anxiety, hypotension, and dyspnea after receiving cefazolin IV, it indicates a severe allergic reaction/anaphylaxis. Epinephrine is the first-line medication for anaphylaxis as it acts quickly to reverse the symptoms by constricting blood vessels, increasing blood pressure, and opening airways. Diphenhydramine (A) is an antihistamine that can be given as a second-line treatment. Albuterol inhaler (B) is used for bronchospasm but is not the first choice in anaphylaxis. Prednisone (D) is a corticosteroid that may be used later for inflammation but is not the initial treatment for anaphylaxis.
A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching is effective?
- A. I will have increased saliva production.
- B. I will continue taking the medication until the rash disappears.
- C. I will taper off the medication before discontinuing it.
- D. I will report any urinary incontinence.
Correct Answer: C
Rationale: The correct answer is C: "I will taper off the medication before discontinuing it." This indicates effective teaching because cyclobenzaprine should not be abruptly stopped to prevent withdrawal symptoms. Tapering off gradually helps the body adjust. Saliva production (A) is not a typical side effect. Continuing until rash disappears (B) is incorrect as it may not be related to the medication. Reporting urinary incontinence (D) is important but not related to proper medication use.
How many mL/h should the nurse set the IV infusion pump to deliver half the total volume of lactated Ringer's (4,080 mL) in the first 8 hours?
- A. 200 mL/h
- B. 225 mL/h
- C. 250 mL/h
- D. 255 mL/h
- E. 275 mL/h
Correct Answer: D
Rationale: The correct answer is D: 255 mL/h. To deliver half of 4,080 mL in 8 hours, you need to administer 2,040 mL in 8 hours. To calculate the infusion rate, divide the total volume by the total time: 2,040 mL ÷ 8 hours = 255 mL/h. This rate ensures half of the total volume is infused within the specified time frame.
Choice A (200 mL/h) is too slow, as it would not deliver half the volume in 8 hours. Choices B, C, and E exceed the required rate and would deliver more than half the volume in 8 hours.
Which of the following actions is the priority for the nurse to take after inadvertently administering 160 mg of valsartan PO to a client who was scheduled to receive 80 mg?
- A. Evaluate the client for orthostatic hypotension
- B. Monitor the client's urine output
- C. Obtain the client's laboratory results
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. After administering a double dose of Valsartan, the priority is to assess the client for potential adverse effects such as a sudden drop in blood pressure, which can lead to orthostatic hypotension. This is crucial to prevent any harm to the client. Monitoring urine output (B) may be important but is not the immediate priority. Obtaining laboratory results (C) would not provide immediate information on the client's current condition. Checking for nasal congestion (D) is irrelevant to the situation.