Nokea
Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism in a client taking haloperidol?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms resembling Parkinson's disease. A shuffling gait, where the client takes small steps with feet barely leaving the floor, is a classic manifestation. Serpentine limb movement (A) is not typically associated with pseudoparkinsonism. Nonreactive pupils (C) can be a sign of anticholinergic toxicity, not pseudoparkinsonism. Smacking lips (D) is more indicative of tardive dyskinesia, another side effect of antipsychotics.
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Which of the following medications should the nurse plan to administer to a client who has heroin toxicity, is unresponsive, has pinpoint pupils, and a respiratory rate of 8/min?
- A. Methadone
- B. Naloxone
- C. Diazepam
- D. Bupropion
Correct Answer: B
Rationale: The correct answer is B: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like heroin. In this scenario, the client's symptoms of unresponsiveness, pinpoint pupils, and respiratory depression indicate opioid toxicity. Naloxone will competitively bind to opioid receptors, reversing respiratory depression and potentially restoring consciousness. Methadone (A) is used for opioid dependence but not acute toxicity. Diazepam (C) is a benzodiazepine and not indicated for opioid toxicity. Bupropion (D) is an antidepressant and not appropriate for this situation.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension. and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. Epinephrine is the first-line treatment for anaphylaxis, which can present with symptoms such as anxiety, hypotension, and dyspnea following administration of a medication like cefazolin. Epinephrine acts quickly to reverse the severe allergic reaction by constricting blood vessels, increasing blood pressure, and opening up the airways to improve breathing. Diphenhydramine (A) is an antihistamine that can be used as an adjunct therapy but is not the first choice in an acute anaphylactic reaction. Albuterol inhaler (B) is used for bronchodilation in asthma, not for managing anaphylaxis. Prednisone (D) is a corticosteroid that may be used later in the treatment process to prevent a late-phase reaction but is not the initial treatment for anaphylaxis.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client. Nursing Action: Document the blood product transfusion in the client's medical record.
- A. Indicated
- B. Not indicated
Correct Answer: A
Rationale: The correct answer is A: Indicated. Documenting the blood product transfusion in the client's medical record is crucial for legal, ethical, and continuity of care reasons. Documentation ensures that all relevant information about the transfusion is recorded accurately, including the type of blood product, volume infused, patient's vital signs, any adverse reactions, and the healthcare provider's orders. This documentation serves as a permanent record of the procedure, aiding in monitoring the patient's response to the transfusion and facilitating communication among healthcare team members. Failure to document the blood transfusion can lead to serious consequences, such as improper monitoring, increased risk of errors, and compromised patient safety. Therefore, documenting the blood product transfusion in the client's medical record is a vital and necessary nursing action. Other choices are incorrect as they do not address the importance of documentation in ensuring safe and effective patient care.
How many mL/h should the nurse set the IV infusion pump to deliver half the total volume of lactated Ringer's (4,080 mL) in the first 8 hours?
- A. 200 mL/h
- B. 225 mL/h
- C. 250 mL/h
- D. 255 mL/h
- E. 275 mL/h
Correct Answer: D
Rationale: The correct answer is D: 255 mL/h. To deliver half of 4,080 mL in 8 hours, you need to administer 2,040 mL in 8 hours. To calculate the infusion rate, divide the total volume by the total time: 2,040 mL ÷ 8 hours = 255 mL/h. This rate ensures half of the total volume is infused within the specified time frame.
Choice A (200 mL/h) is too slow, as it would not deliver half the volume in 8 hours. Choices B, C, and E exceed the required rate and would deliver more than half the volume in 8 hours.
Which of the following medications should the nurse anticipate administering to a client who has taken a large amount of diazepam?
- A. Ondansetron
- B. Magnesium Sulphate
- C. Flumazenil
- D. Protamine Sulphate
Correct Answer: C
Rationale: The correct answer is C: Flumazenil. Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, such as diazepam. It competes with benzodiazepines at the receptor site, reversing their sedative and hypnotic effects. Ondansetron (A) is an antiemetic, Magnesium Sulphate (B) is used for various conditions like pre-eclampsia, Protamine Sulphate (D) is used to reverse heparin anticoagulation. Flumazenil is the most appropriate choice for reversing the effects of diazepam overdose.