Nokea
The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive
- A. Acetylcysteine
- B. Benztropine
- C. Phentolamine
- D. Flumazenil
Correct Answer: D
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (A) treats acetaminophen overdose, benztropine (B) manages extrapyramidal symptoms, and phentolamine (C) treats hypertensive crises, none of which apply here.
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A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
- A. Notify the provider
- B. Palpate the anterior fontanel
- C. Examine the posterior fontanel
- D. Record these normal findings
Correct Answer: D
Rationale: Record these normal findings. Head and chest circumferences are typically equal by 1 to 2 years of age.
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
- A. Aphasia
- B. Apraxia
- C. Dysarthria
- D. Dysphagia
Correct Answer: A
Rationale: Aphasia (A) is a language disorder causing difficulty with word choice or expression, common in stroke affecting language centers. The client’s ability to follow commands but use incorrect words suggests expressive aphasia. Apraxia (B) affects motor planning, dysarthria (C) impairs speech articulation, and dysphagia (D) involves swallowing difficulties, none of which match the described deficit.