Nokea
The nurse is caring for a young adult patient who has inhaled cocaine and has been admitted to the emergency department with palpitations and shortness of breath. Which of the following actions ordered by the health care provider will the nurse implement first?
- A. Obtain a 12-lead ECG.
- B. Start O2 at 4 L/minute.
- C. Draw blood for drug screening.
- D. Infuse normal saline at 100 mL/hour.
Correct Answer: B
Rationale: The priority here is to ensure that oxygenation is adequate. The other orders also should be accomplished as soon as possible but are not the first priority.
You may also like to solve these questions
The nurse is caring for a patient admitted to hospital with chest pain who is a pack-a-day smoker and tells the nurse, 'I am just not ready to quit smoking yet.' Which of the following responses is the most appropriate?
- A. This would be a really good time to quit.
- B. Your smoking is the cause of your chest pain.
- C. Do you think that smoking has caused any health problems?
- D. Are you familiar with the various nicotine replacement options?
Correct Answer: C
Rationale: The patient is in the precontemplation stage of change, and the nurse's role is to assist the patient in identifying motivators to quitting. The current Clinical Practice Guidelines indicate that the nurse should ask the patient to identify any negative consequences from smoking. The responses 'This would be a really good time to quit.' and 'Your smoking is the cause of your chest pain.' express judgmental feelings by the nurse and are not likely to motivate the patient. Providing information about the various nicotine replacement options would be appropriate for a patient who has expressed a desire to quit smoking.
The nurse is caring for a patient with alcohol dependence who has been admitted to the hospital with chest pain. Twenty-four hours after admission, the patient becomes very tremulous and anxious. Which of the following actions should the nurse implement?
- A. Insert an IV line and infuse fluids.
- B. Promote oral intake to 3000 mL/day.
- C. Provide a quiet, well-lit environment.
- D. Administer opioids to provide sedation.
Correct Answer: C
Rationale: The patient's symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help to decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.
The nurse is caring for a young adult who has a cocaine addiction. Which of the following routes of cocaine administration results in the fastest absorption and the highest 'rush'?
- A. Smoking
- B. Buccal
- C. Oral
- D. Intranasal
Correct Answer: A
Rationale: Smoking and intravenous (IV) methods result in the fastest absorption and the highest 'rush'.
The nurse is caring for a patient who takes methadone daily to prevent a relapse of heroin addiction and has been admitted for knee surgery. Which of the following actions should the nurse include in the plan of care to promote effective pain control postoperatively?
- A. Use a mixed opioid agonist-antagonist drug for pain relief.
- B. Administer opioid analgesics on a regularly scheduled basis.
- C. Avoid use of opioids and use alternatives such as NSAIDs.
- D. Give prescribed doses of opioid pain medication as needed for pain.
Correct Answer: B
Rationale: A patient addicted to opioids should receive them on an around-the-clock basis to prevent withdrawal. Normal opioid doses given on a PRN basis will not effectively relieve pain in a patient who has developed tolerance. NSAIDs may be used as adjuncts, but they should not be the primary analgesic used. Mixed opioid agonist-antagonist drugs can precipitate withdrawal in patients who have tolerance to opioids.
During physical assessment of a patient who has sinus headaches, the nurse finds nasal sores and necrosis of the nasal septum. Patient use of which of the following substances should the nurse include in the assessment?
- A. Heroin
- B. Cocaine
- C. Tobacco
- D. Marijuana
Correct Answer: B
Rationale: When cocaine is inhaled, it causes ischemia of the nasal septum, leading to nasal sores and necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana.