The nurse is performing an ongoing assessment on a client admitted to the post-anesthesia care unit at 1655 following abdominal surgery. The nurse documents vital signs every five minutes, as noted in the Vital Signs Record. After reviewing the vital sign trends and notifying the provider, the nurse should anticipate administering what medication?

Midazolam (Versed)

Naloxone (Narcan)

Atropine (Atropen)

Dantrolene (Dantrium)

The correct answer is B.

Answer and Explanation

The Correct Answer is B

A. Midazolam (Versed): This is a benzodiazepine used for sedation. It is not typically used in the post-anesthesia care unit unless there is a need for additional sedation or anxiolysis, which is not indicated based on the scenario.
B. Naloxone (Narcan): This is the correct choice. Naloxone is used to reverse opioid-induced respiratory depression. If the vital signs indicate respiratory depression or decreased oxygen saturation potentially due to opioid medications used during surgery, naloxone would be administered.
C. Atropine (Atropen): This medication is used to treat bradycardia (slow heart rate) and is not typically indicated based on vital signs trends without specific symptoms.
D. Dantrolene (Dantrium): This medication is used to treat malignant hyperthermia, a rare but serious condition often triggered by certain anesthetics. It would be indicated if there were signs of this condition, such as a high fever and muscle rigidity, which is not mentioned in the scenario.

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Correct Answer is ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

A. Dry oral mucus membranes B. Weight loss C. Jugular vein distention D. Daily urine output of 960 mL E. Daily urine output of 960 mL

Correct Answer is D

Explanation

A. Dry oral mucus membranes: This finding indicates dehydration rather than improvement. Effective treatment would result in the rehydration of mucous membranes.
B. Weight loss: Weight loss can be a sign of ongoing dehydration or fluid loss. Effective treatment would be indicated by weight stabilization or gain, not loss.
C. Jugular vein distention: Jugular vein distention typically indicates fluid overload or poor cardiac function, not improvement in dehydration. Effective rehydration would be associated with a return to normal vein appearance.
D. Daily urine output of 960 mL: This is the correct choice as it reflects adequate fluid intake and kidney function. For an average adult, a daily urine output of around 960 mL suggests proper hydration, indicating that interventions have been effective.

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Naxlex Comprehensive Predictor Exams

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing care for a hospitalized client admitted with dehydration. Which assessment finding indicates interventions have been effective?

Correct Answer is D

Explanation

The nurse is providing care for several clients at risk for acid-base imbalance. Which client has the greatest risk for respiratory acidosis?

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

A client with peripheral neuropathy states, "I don't know why the doctor put me on an antidepressant. I am not depressed!" Which response by the nurse is best?

When planning nutritional interventions for a healthy 83-year-old man, the nurse recognizes what factor is most likely to affect his nutritional status?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)