Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is experiencing opioid intoxication. Which of the following findings should the nurse expect?
A. Abdominal cramps
Abdominal cramps are not typically associated with opioid intoxication.
B. Slurred speech
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
C. Tachycardia
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
D. Diaphoresis
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
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Full Explanation
Choice A rationale:
Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
Choice C rationale:
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
Choice D rationale:
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
Similar Questions
A nurse is caring for a client who is suspected to have developed sensitivity to latex.
Which of the following interventions should the nurse plan to implement?
A. Use a disposable adhesive probe when measuring the client's SaO2
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
B. Wrap a blood pressure cuff in a stockinette for use in the client's room.
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
C. Document in the medical record that the client should not use silicone products.
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
D. Clean vial stoppers for 15 seconds before using them to withdraw-medications for the client.
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
Full Explanation
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
A nurse is teaching the parent of an infant about the varicella virus vaccine. Which of the following statements by the parent indicates an understanding of the teaching?
A. "My child should not receive the vaccine if she is allergic to eggs."
Allergic reactions to eggs are a concern with some vaccines, but the varicella vaccine is generally considered safe for children with egg allergies.
B. "There is a series of three doses of the vaccine that my child will receive."
The varicella vaccine is typically given in two doses, not three.
C. "My child should not take aspirin for 6 weeks following vaccination."
Children should avoid taking aspirin for about 6 weeks after receiving the varicella vaccine to reduce the risk of Reye's syndrome, a rare but serious condition associated with aspirin use during viral infections.
D. "The vaccine will be injected into the muscle of my child's upper arm."
The varicella vaccine is usually administered subcutaneously, not into the muscle.
Full Explanation
Choice A rationale:
Allergic reactions to eggs are a concern with some vaccines, but the varicella vaccine is generally considered safe for children with egg allergies.
Choice B rationale:
The varicella vaccine is typically given in two doses, not three. Choice C rationale:
Children should avoid taking aspirin for about 6 weeks after receiving the varicella vaccine to reduce the risk of Reye's syndrome, a rare but serious condition associated with aspirin use during viral infections.
Choice D rationale:
The varicella vaccine is usually administered subcutaneously, not into the muscle.
A nurse is creating a plan of care for an infant who has osteogenesis imperfecta. Which of the following interventions should the nurse include in the plan?
A. Use pillows to position the infant when changing a diaper.
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
B. Instruct the parents to withhold immunizations until 1 year of age.
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
C. Obtain the infant's blood pressure with an automatic cuff.
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
D. Avoid using splints to support the infant's limbs
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
Full Explanation
Choice A rationale:
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
Choice B rationale:
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
Choice C rationale:
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
Choice D rationale:
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
