Nokea
Select the opioid classification that is accurately coupled with an example of it AND a side effect or adverse reaction to it.
- A. Opioid Agonist: Dilaudid: Constipation
- B. Opioid Agonist: Naloxone: Constipation
- C. Opioid Antagonist: Dilaudid: Anaphylaxis
- D. Opioid Antagonist: OxyContin: Anaphylaxis
Correct Answer: A
Rationale: Dilaudid (hydromorphone) is an opioid agonist, and constipation is a common side effect due to opioid effects on the gastrointestinal tract.
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A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.
- A. Vital signs.
- B. Decreased urine output.
- C. Level of consciousness.
- D. Motor strength.
Correct Answer: C,A,D,B
Rationale: Level of consciousness is the priority to assess neurological status, followed by vital signs for stability, motor strength for deficits, and urine output for systemic effects.
The mother of a 28-year-old client who is taking clozapine [Clozaril] states, 'Something is wrong. My son is drooling like a baby.' Which of the following responses by the nurse would be most helpful?
- A. I wonder if he's having an adverse reaction to the medicine.'
- B. Excess saliva is common with this drug; here's a paper cup for him to spit into.'
- C. Don't worry about it; this is only a minor inconvenience compared to its benefits.'
- D. I've seen this happen to other clients who are taking Clozaril.'
Correct Answer: B
Rationale: Excess salivation is a common side effect of clozapine. Providing a practical solution like a cup supports the client's comfort and addresses the mother's concern.
The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places priority on discussing which risk factor with this client?
- A. Age older than 30 years
- B. High-fat and low-fiber diet
- C. Distant relative with colorectal cancer
- D. Personal history of ulcerative colitis or gastrointestinal polyps
Correct Answer: B
Rationale: Clients should be aware of modifiable risk factors as part of general health maintenance and primary disease prevention. Modifiable risk factors are those that can be reduced and include a high-fat and low-fiber diet. Common risk factors for colorectal cancer that cannot be changed include age older than 40 years, first-degree relative with colorectal cancer, and history of bowel problems such as ulcerative colitis or familial polyposis.
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.