The nurse is caring for a client in the emergency department who has overdosed on morphine. Which medication does the nurse anticipate to be ordered to reverse the effects of morphine?
- A. sodium bicarbonate
- B. flumazenil
- C. diphenhydramine
- D. naloxone
Correct Answer: D
Rationale: Naloxone is an opioid antagonist used to reverse morphine overdose effects, such as respiratory depression.
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A client with a fractured right femur has not had any immunizations since childhood. Which of the following biological products should the nurse administer to provide the client with passive immunity for tetanus?
- A. Tetanus toxoid.
- B. Tetanus antigen.
- C. Tetanus vaccine.
- D. Tetanus antitoxin.
Correct Answer: D
Rationale: Tetanus antitoxin provides passive immunity, neutralizing existing toxin in unvaccinated clients.
Which of the following hospitalized clients is at risk to develop parotitis?
- A. A 50-year-old client with nausea and vomiting who is on nothing-by-mouth status.
- B. A 75-year-old client with diabetes who has ill-fitting dentures.
- C. An 80-year-old client who has poor oral hygiene and is dehydrated.
- D. A 65-year-old client with lung cancer who has a feeding tube in place.
Correct Answer: C
Rationale: Dehydration and poor oral hygiene in the 80-year-old client increase the risk of parotitis due to reduced saliva production and bacterial overgrowth.
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:
- A. Decrease circulatory overload.
- B. Improve the myocardial workload.
- C. Prevent thrombus formation.
- D. Regulate cardiac rhythm.
Correct Answer: C
Rationale: Warfarin prevents thrombus formation, critical in atrial fibrillation and low ejection fraction, which increase clot risk due to stasis.
The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is appropriate for the nurse to take to correct the problem?
- A. Readjust the solution to infuse the desired amount.
- B. Continue the infusion at the current rate, but run the next bottle at an increased rate.
- C. Double the infusion rate for 2 hours.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is appropriate when a TPN infusion is behind schedule, as adjusting rates without an order can cause complications like hyperglycemia or circulatory overload. Continuing at the current rate or doubling the rate is unsafe. CN: Pharmacological and parenteral therapies; CL: Synthesize
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