Nokea
When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to:
- A. Ventilate with an oxygenated Ambu bag.
- B. Shock the client with ECG paddles.
- C. Administer 0.5 mL 1:1000 epinephrine.
- D. Titrate flumazenil (Romazicon).
Correct Answer: D
Rationale: Flumazenil is the specific reversal agent for benzodiazepine overdose, such as with midazolam. Titrating flumazenil reverses sedation and respiratory depression effectively.
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A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
- A. Provide access for wound irrigation.
- B. Promote drainage of wound exudate.
- C. Minimize development of scar tissue.
- D. Decrease postoperative discomfort.
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.
Which client position is contraindicated for a client with a spinal cord injury?
- A. Supine with head flat.
- B. Logrolling technique.
- C. Head elevated 30 degrees.
- D. Neutral neck alignment.
Correct Answer: A
Rationale: Supine with head flat is contraindicated as it may increase spinal pressure; other positions support alignment and safety.
The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin.
- B. Steroids.
- C. Sulfonylureas.
- D. Angiotensin-converting enzyme (ACE) inhibitors.
Correct Answer: B
Rationale: Steroids can increase blood glucose levels, complicating diabetes management by causing hyperglycemia.
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
- A. Reflexes.
- B. Bladder function.
- C. Blood pressure.
- D. Temperature.
- E. Respirations.
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.