Nokea
The nurse is reviewing the plan of care for multiple clients receiving opioids for pain management. Which client has the greatest risk for respiratory depression?
- A. 20-year-old client with chronic bronchitis who is receiving inhaled albuterol therapy every 4 hours
- B. 30-year-old client with opioid use disorder who had rotator cuff repair surgery this morning
- C. 50-year-old client with sleep apnea and left foot cellulitis who is scheduled for a bone scan later today
- D. 70-year-old client with chronic obstructive pulmonary disease who had knee replacement this morning
Correct Answer: D
Rationale: The 70-year-old with COPD is at highest risk for opioid-induced respiratory depression due to age-related reduced lung capacity and COPD-related impaired gas exchange. Chronic bronchitis and opioid use disorder increase risk but are less severe in this context.
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A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?
- A. I can stop taking the medication once my symptoms improve
- B. I must eat a healthy diet and exercise regularly to reduce weight gain
- C. I should feel better within 1 week after starting this medication
- D. I will experience improved sexual performance with this medication
Correct Answer: B
Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.
The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.
- A. Client determined brain dead was taken off life support
- B. Client with alcohol intoxication physically assaulted a nurse
- C. Serum troponin level was prescribed but never obtained
- D. Staff nurse did not present for work and did not notify management
- E. Visitor fell and refused care in the emergency department
Correct Answer: B,C,D
Rationale: Assault, missed lab tests, and staff no-show are reportable incidents due to safety, care quality, and staffing issues. Brain death withdrawal follows protocol, and a visitor’s fall with refused care is less reportable.
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
- A. How to transmit the readings over the phone
- B. Keep a diary of activities and any symptoms experienced
- C. Refrain from exercising while wearing the monitor
- D. The monitor may be removed only when bathing
Correct Answer: B
Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.
The nurse is caring for an elderly woman who had surgery on her right foot yesterday. The woman had a broken left arm three months ago and has osteoarthritis. Which type of assistive device will probably be most appropriate for this client?
- A. Quad cane
- B. Crutches
- C. Walker
- D. Tripod cane
Correct Answer: C
Rationale: A walker provides maximum stability for an elderly woman with recent foot surgery, prior arm injury, and osteoarthritis, ensuring safe ambulation.