Patient Data

Which should the nurse do immediately? Select all that apply.

Print an electrocardiogram strip

Call for rapid response

Perform chest compressions

Apply oxygen via nasal cannula

Give naloxone 2 mg intravenous push

Provide rescue breaths with a manual ventilation bag

Answer and Explanation

Correct Answer : B,E,F

A. Print an electrocardiogram strip: While cardiac monitoring is important, printing an ECG strip does not immediately address the critical issue of respiratory depression and unresponsiveness. Priority actions must focus on airway and breathing first.

B. Call for rapid response: The client is critically unstable with severe respiratory depression and unresponsiveness, meeting criteria for a rapid response or even a code blue if the situation deteriorates further. Immediate expert team support is crucial.

C. Perform chest compressions: Chest compressions are only indicated if the client is pulseless. In this case, the client has a heart rate of 92 beats/minute, meaning compressions are not appropriate at this moment.

D. Apply oxygen via nasal cannula: A nasal cannula would not deliver high enough oxygen concentrations for someone with a respiratory rate of 5 breaths/minute and oxygen saturation of 54%. Higher oxygen delivery methods and ventilatory support are urgently needed.

E. Give naloxone 2 mg intravenous push: Naloxone is indicated immediately to reverse opioid-induced respiratory depression. Giving the prescribed naloxone IV push can rapidly counteract the morphine overdose and improve the client’s respiratory effort.

F. Provide rescue breaths with a manual ventilation bag: Because the client’s respirations are critically low, rescue breathing with a manual resuscitation bag is necessary to maintain oxygenation and ventilation until naloxone takes effect or more advanced airway management is available.

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Correct Answer is B

Explanation

A. Do you perform regular testicular self-examinations?: While important for early detection of testicular cancer, this question does not directly address the concern about testicular shrinkage, which is more likely linked to hormonal influences or substance use.

B. Are you taking any type of anabolic steroids?: Anabolic steroid use can suppress natural testosterone production, leading to testicular atrophy or shrinkage. Identifying steroid use is critical because it directly relates to the reported symptom and can have significant long-term health consequences.

C. Do you use any type of herbal supplements?: Herbal supplements can sometimes affect hormone levels, but they are far less likely than anabolic steroids to cause noticeable testicular shrinkage.

D. How many hours a day do you spend exercising?: While excessive exercise can impact overall hormonal balance, it is unlikely by itself to cause significant testicular shrinkage. Directly investigating anabolic steroid use is a much higher priority based on the symptom described.

A. Use a stool softener as needed. B. Discontinue when spasms cease. C. Avoid the ingestion of alcohol. D. Take medication with meals.

Correct Answer is B

Explanation

A. Use a stool softener as needed: Baclofen can cause constipation as a side effect due to its muscle-relaxant properties. Using a stool softener as needed is an appropriate and safe strategy to manage this potential issue without needing additional instruction.

B. Discontinue when spasms cease: Baclofen should not be abruptly discontinued because sudden withdrawal can lead to serious complications such as seizures, hallucinations, or rebound spasticity. Clients must be taught to taper the medication gradually under healthcare provider supervision.

C. Avoid the ingestion of alcohol: Alcohol can potentiate the central nervous system depressant effects of baclofen, increasing the risk of sedation, dizziness, and respiratory depression. Clients should be advised to avoid alcohol while on this medication.

D. Take medication with meals: Taking baclofen with meals helps reduce gastrointestinal upset, such as nausea, which can occur with muscle relaxants. This practice is appropriate and does not require additional instruction.

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Patient Data Which should the nurse do immediately? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young male athlete tells the nurse that he is concerned because his testicles seem to be shrinking. Which question is most important for the nurse to ask this client?

Correct Answer is B

Explanation

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is B

Explanation

Patient Data Review H and P, nurse's notes, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the bisacodyl administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

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Which assessment finding indicates to the nurse that the prescription bethanechol is effective for a client diagnosed with urinary retention?

The nurse mixes diphenhydramine 25 mg in a 100 mL bag of 0.9% sodium chloride, which is to be administered IV over 30 minutes. The IV pump should be set to administer how many mL/hour? (Enter numeric value only.)

The nurse is administering IV fluconazole to a client who has systemic candidiasis. After reviewing the client's diagnostic studies, the nurse identifies a rising trend in the liver enzyme levels for aspartate aminotransferase (AST). Which action should the nurse implement?

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?

The nurse determines that a client has been taking antidepressants for the past six months. Which symptoms are common side effects of this medication classification?

A client has a prescription for clopidogrel bisulfate 75 mg by mouth daily at 0900. In which situation should the nurse hold this medication?

Patient Data

Which should the nurse do immediately? Select all that apply.