Nokea
The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
- A. Administer the medication as a 2-mg bolus.
- B. Give the medication undiluted in incremental doses.
- C. Be alert for shivering and hypotension.
- D. Use only a free-flowing I.V. line in a large vein.
- E. Monitor the client's level of consciousness.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (B), via a free-flowing IV line (D), with monitoring for side effects like shivering and hypotension (C) and level of consciousness (E). A 2-mg bolus (A) is incorrect, as flumazenil is titrated in smaller doses.
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Which symptom indicates a potential complication in a client post-craniotomy?
- A. Mild headache.
- B. Clear nasal drainage.
- C. Stable blood pressure.
- D. Improved appetite.
Correct Answer: B
Rationale: Clear nasal drainage may indicate cerebrospinal fluid leakage, a serious post-craniotomy complication.
Which activity increases the risk of renal calculi?
- A. High fluid intake.
- B. Sedentary lifestyle.
- C. Low-sodium diet.
- D. Frequent urination.
Correct Answer: B
Rationale: A sedentary lifestyle promotes urinary stasis, increasing stone risk.
The nurse is teaching the client and family how to manage possible nausea and vomiting at home. The nurse should include information about:
- A. Eating frequent, small meals throughout the day.
- B. Eating three normal meals a day.
- C. Eating only cold foods with no odor.
- D. Limiting the amount of fluid intake.
Correct Answer: A
Rationale: Eating frequent, small meals helps prevent nausea by avoiding an empty or overly full stomach, which can trigger vomiting during chemotherapy.
The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
- A. Emboli formation.
- B. Fluid volume overload.
- C. Red blood cell hemolysis.
- D. Allergic reaction.
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.