Nokea
The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:
- A. Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
- B. Check respirations in 30 minutes because the effects of morphine will have worn off by then.
- C. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
- D. Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
Correct Answer: C
Rationale: Naloxone has a shorter half-life than morphine, so respiratory depression may recur. Frequent monitoring for 4-6 hours ensures timely detection and additional doses if needed.
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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.
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should:
- A. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
- B. Explain how to overcome a freezing gait by telling the client to march in place.
- C. Assist the nursing assistant with getting the client back in bed.
- D. Give the client a muscle relaxant.
Correct Answer: B
Rationale: Teaching the client to march in place helps overcome freezing gait, a common Parkinson's symptom. Pulling on arms is unsafe, returning to bed is unnecessary, and muscle relaxants are inappropriate.
The nurse is caring for a client interested in pre-exposure prophylaxis for human immunodeficiency virus (HIV). Which prescription would the nurse anticipate?
- A. Voriconazole
- B. Tenofovir-emtricitabine
- C. Raloxifene
- D. Lurasidone
Correct Answer: B
Rationale: Tenofovir-emtricitabine (Truvada) is approved for pre-exposure prophylaxis (PrEP) to prevent HIV infection in high-risk individuals. Choice A (voriconazole) is an antifungal, Choice C (raloxifene) is for osteoporosis, and Choice D (lurasidone) is an antipsychotic.