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?

Naloxone

Protamine sulfate

Acetylcysteine

Flumazenil

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.

A. Sore throat B. SaO, 92% C. Stridor D. Rhonchi

Correct Answer is C

Explanation

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Correct Answer is C

Explanation

The nurse is reviewing the client's medical record. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

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