Nokea
The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse finds increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate?
- A. Bolus dose of IV morphine
- B. Incentive spirometer.
- C. IV furosemide
- D. Non-rebreather mask
Correct Answer: B
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, which is likely causing the observed respiratory symptoms.
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The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
- A. Antabuse (disulfiram)
- B. Romazecon (flumazenil)
- C. Dolophine (methodone)
- D. Ativan (lorazepam)
Correct Answer: D
Rationale: Ativan (lorazepam), a benzodiazepine, is used to manage alcohol withdrawal symptoms like seizures and agitation. Antabuse deters drinking, flumazenil reverses benzodiazepines, and methadone treats opioid withdrawal.
The nurse is observing the movements of a client receiving Thorazine (chlorpromazine). The client continually paces and rocks back and forth when sitting. The nurse recognizes that the client is experiencing:
- A. Oculogyric crisis
- B. Akathisia
- C. Dystonia
- D. Bradykinesia
Correct Answer: B
Rationale: Akathisia is characterized by restlessness, pacing, and rocking, which matches the client's symptoms. Answer A involves fixed upward gaze, Answer C involves muscle spasms, and Answer D involves slowed movements, all of which are incorrect.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.