The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.
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Which observation, if reported by a client, is most suggestive of an adverse reaction to gentamicin?
- A. A WBC of 8000
- B. Ringing in the ears
- C. Itching
- D. Nasal stuffiness
Correct Answer: B
Rationale: Gentamicin is ototoxic. Ringing in the ears suggests possible damage to the eighth cranial nerve, the auditory nerve. A WBC of 8000 is normal.
A client is scheduled for an intravenous pyelogram (IVP). After the contrast material is injected, which of the following client reactions should be reported immediately?
- A. Feeling warm
- B. Face flushing
- C. Salty taste
- D. Hives
Correct Answer: D
Rationale: Hives. This is a sign of anaphylaxis and should be reported immediately. The other reactions are considered normal and the client should be informed that they may occur.
An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
An adult received regular insulin at 7:00 A.M. At 10:00 A.M., she is irritable and sweaty, but her skin is cool. What is the most appropriate action for the nurse to take?
- A. Have her lie down for a rest
- B. Give her a cola drink
- C. Give ordered insulin
- D. Encourage exercise
Correct Answer: B
Rationale: Irritability, sweating, and cool skin suggest hypoglycemia. A cola drink provides quick-acting carbohydrates to raise blood sugar.
A 48-year-old man is in the emergency room. He has crushing substernal pain and is diaphoretic, apprehensive, and ashen gray in color. The cardiac monitor shows runs of premature ventricular contractions. Which drug is most likely to be given to this client?
- A. Lidocaine
- B. Verapamil
- C. Digitalis
- D. Nitroglycerin
Correct Answer: A
Rationale: Lidocaine is used to treat ventricular arrhythmias, such as premature ventricular contractions, in acute coronary syndrome.