Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?
A. Naloxone
Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate
Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid- induced respiratory depression and hypotension.
C. Acetylcysteine
Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil
Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.
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Full Explanation
A. Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid-induced respiratory depression and hypotension.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.
Similar Questions
A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?
A. Apply mitten restraints to prevent the client from disconnecting their tube feeding.
In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.
The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Apply soft heel protectors bilaterally while client is in bed.
Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
Full Explanation
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
A. Weight gain
Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen
Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. Confusion
While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. Dyspnea
This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
Full Explanation
A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
A. Alopecia
Malnutrition can lead to inadequate intake of essential nutrients, such as vitamins and minerals, which are necessary for maintaining healthy hair growth.
B. Diplopia
Double vision, or diplopia, is more commonly associated with neurological or ocular conditions rather than malnutrition.
C. Oily skin
Malnutrition may result in dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.
D. Increased salivation
While malnutrition can affect various physiological processes, increased salivation is not a common manifestation of mal
Full Explanation
A. Malnutrition can lead to inadequate intake of essential nutrients, such as vitamins and minerals, which are necessary for maintaining healthy hair growth.
B. Double vision, or diplopia, is more commonly associated with neurological or ocular conditions rather than malnutrition.
C. Malnutrition may result in dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.
D. While malnutrition can affect various physiological processes, increased salivation is not a common manifestation of mal