Skills - Assessment 2 (NCLEX Questions)

2. A nurse is admitting a toddler to the hospital after an Acetaminophen overdose. Which of the following medications should the nurse anticipate administering to this client? a. Acetylcysteine b. Narcan c. Flumazenil d. Dantrium (Dantrolene Sodium)

(A Acetylcysteine is the correct antidote for Acetaminophen overdose. Narcan is for opioid overdose, Flumazenil is for Diazepam overdose and Dantrium is for Malignant Hyperthermia.)

1. A patiënt with emphysema is prescribed a corticosteroid. Which of the following side effects should the nurse instruct the patient about in the discharge instructions? SELECT ALL THAT APPLY A. Cough B. Oral candidiasis C. Hoarseness D. Dry mouth E. Fatigue

(A, B, C, D) (cough, hoarseness, dry mouth, and a risk of developing oral candidiasis are all known side effects of corticosteroids. Corticosteroids are not known to cause fatigue.)

The client with acute mania is prescribed 500mg lithium PO three times a day. The healthcare provider also prescribes 5mg of haloperidol PO for bedtime. Which action should the nurse take? 1. Administer the medications as prescribed 2. Question the Healthcare provider about the prescription 3. Administer the haloperidol but not the lithium 4. Consult with the nursing supervisor before administering the medications

1 (lithium has a therapeutic lag time of 1-2weeks. Haloperidol is prescribed temporarily to produce a neuroleptic effect and discontinued when the lithium starts to take effect. )

What are some labs the nurse should watch for when giving acetaminophen to an alcoholic with severe liver damage? Select all that apply. 1 AST 2 ESR 3 Bilirubin 4 PT 5 A1C

1, 3, 4 (AST, Bilirubin, and PT are all tests that measure liver function. ESR is a test to measure inflammation. A1C is a test to measure long-term glucose levels.)

The healthcare provider prescribes fluoxetine to a 72 year old patient with depression. Which transient adverse effect requires immediate attention by the nurse? 1. Nausea 2. Dizziness 3. Sedation 4. Dry mouth

2 ( The presence of dizziness could indicate orthostatic hypotension which may place the patient at risk for falls)

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side/adverse effects of the medication? 1. Cardiovascular symptoms 2. GI symptoms 3. Problems with mouth dryness 4. Problems with excessive sweating

2 (The most common side effects related to this medication include CNS and GI system dysfunction. Fluoxetine affects the GI system by causing nausea and vomiting, cramping, and diarrhea. CV symptoms, dry mouth, and excessive sweating are not side effects associated with this medication.)

A patient with a diagnosis of asthma has responded well to treatment with oral corticosteroids and a switch to inhaled corticosteroids is planned. What strategy for managing this change in treatment should be implemented? 1 The inhaled drug should begin 3-4 weeks before starting to taper the oral drug 2 The inhaled drug should be started during tapering of the oral drug 3 The two drugs should be taken simultaneously for 10-12 weeks 4 The patient should stop taking the oral drug approximately 1 week prior to starting the inhaled drug.

2 (When a patient is being switched from an oral to an inhaled corticosteroid, the inhaled drug should be started during the tapering of the oral drug. Approximately 1-2 before discontinuing or reaching the lowest anticipated dose of the oral drug)

A nurse is caring for a an older adult who has been admitted for cirrhosis, with signs of decreased cognition and now has developed constipation due to immobility. Which GI medication would be most effective in treating this patient with these conditions? 1. Pysyllium (Metamucil) 2. Lactulose 3. Saline cahartics (Miralax) 4. Mylanta

2. (This is the most correct answer out of the choices because lactulose is a laxative that will help reduce constipation. However, what's unique about this specific laxative is that it also can decrease ammonia levels. This is super important for a patient with cirrhosis who is showing signs of decreased cognition because they could be experiencing hepatic encepalopathy which happens from increased ammonia levels. Incorrect answers: Mylanta is used for GERD, and the other laxatives do not have the capability of decreasing ammonia and therefore it's in the patients best interest to use a medication that can treat both symptoms. )

The plan of care for a patient who takes lithium (Lithobid) should include: 1. dietary teaching to restrict daily sodium intake 2. periodic laboratory monitoring of renal and thyroid function 3. the requirement for laboratory tests to monitor serum potassium level 4. the importance of discontinuing the medication if fine hand tremor occurs

2. (periodic laboratory monitoring of renal and thyroid function Two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidney's ability to concentrate urine; therefore, a person receiving lithium therapy must have periodic follow-ups to assess thyroid and renal function. Weight gain and fine tremors are common side effects associated with this medication, but the patient should continue taking the medication. Sodium intake for clients who take lithium is not restricted.)

The client with a major depressive disorder taking the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) calls the psychiatric clinic and reports feeling confused and restless and having an elevated temperature. Which action should the psychiatric nurse take? 1. Determine if the client has flulike symptoms 2. Instruct the client to stop taking the SSRI 3. Recommend the client take the medication at night. 4. Explain that these are expected side effects

2. (Instruct the client to stop taking the SSRI Serotonin syndrome is a serious complication of SSRIs that produces mental changes (confusion, anxiety, and restlessness), hypertension, tremors, sweating, hyperpyrexia (elevated temperature), and ataxia. Conservation treatment includes stopping the SSRI and supportive treatment. If untreated, ESE can lead to death)

Patients taking corticosteroid medication should be asked about any recent history of? 1 Antidepressant use 2 Cognitive disorders 3 Urinary incontinence 4 Infections

4 ( Corticosteroids are contraindicated in fungal infections)

A patient has received a prescription for a MAO Inhibitor. The nurse is reviewing the patient's medical history. Which finding made the nurse question the provider on the oder. 1) Patient stopped taking albuterol 3 weeks ago 2) Patient is lactose intolerant, and he specifically avoids cheese 3) Patient stopped taking lithium 3 weeks ago 4) Patient stopped taking fluoxetine 3 weeks ago.

4 ( Usually you need to avoid certain meds for 14 days before taking a MAO Inhibitor. While most SSRIs only need 14 days, fluoxetine needs 5 weeks to be cleared before you can take a MAO inhibitor. for number 2, if the patient ate certain cheeses that contained tyramine, that would cause concern, but since he does not, it's not a concern.)

2) Frequent use of bronchodilators may cause all the following side effects except: a. blurred vision b. increased heart rate c. nervousness d. tremors

A

A nurse is preparing to to administer a bronchodilator to a client who has asthma. Which of the following is a common side effect of these drugs for which the nurse should monitor? A Restlessness B Ataxia C Nystagmus

A (Restlessness is a common side effect of bronchodilators because of central nervous system stimulation.)

2. When administering long-term systemic corticosteroid medications, which of the following dosing schedules is recommended? a. alternate-day therapy b. once daily at noon c. weekly therapy d. nightly therapy .

A (It is recommended that systemic corticosteroid medications be administered on alternate days. The dose administered is two times the normal daily dose)

(2) A nurse is preparing to administer a bronchodilator to a client who has asthma. Which of the following is a common side effect of these drugs for which the nurse should monitor? A. Restless B. Nystagmus C. Ataxia D. Gingival hyperplasia

A (Restlessness is a common side effect of bronchodilators because of central nervous system stimulation.)

A nurse is teaching a patient with severe schizophrenia about Clozaril (clozapine). The patient questions why he needs to return in 1 weeks time for blood work. Which of the following is the most appropriate nursing response? A) "Weekly blood test are necessary to determine safe dosage and to monitor the effect of the medication on the blood." B) "Your physician will want to know how well you are progressing with the medication therapy." C) "Everyone taking Clozapine has to go through the same procedure because it is required by the drug company." D) "Weekly blood tests are done so that you can receive another week's supply of the medication."

A (The client needs specific information about the effects of the drug, specifically its effect on the blood. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow up with the required protocol for Clorazil therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. It is also true that the medication is given out only in a one week supply and the provider will want to know how well the patient is progressing, but the correct response is one that will help the client understand and thereby follow through with appointments.)

A nurse is performing medication reconciliation with a patient. The client complains of a severe headache and states that they have been taking 600-800 mg of Acetaminophen every 6 hours for the past 3 days. What is the first thing the nurse should do? A. Ask the patient what other OTC medications they have been taking. B. Stop and assess the patient for adverse symptoms from taking more than the recommended daily limit for this medication. C. Consult with the provider about ordering a prescription medication to help control the patients pain D. Educate the patient about the complications associated with taking too much Acetaminophen.

A ( The patient reports taking less than the recommended total daily dose for Acetaminophen (< 4000 mg), but it is necessary to find out if they may be taking other OTC medications that may contain further Acetaminophen. Further information is needed before action can be taken.)

1) how should a nurse manage pain in a client with a history of drug abuse? A)Provide adequate pain relief B)Provide half the pain medication ordered C)Give extra pain medication because this patient will have a increased tolerance D)Don't provide medication because they will become addicted

A (because if this person doesn't get adequate treatment they will get under treated and possibly start using drug seeking behaviors and may also go into withdrawals)

which of the following findings is a factor in the development of lithium toxicity? A. Hyponatremia B. Hypercalcemia C. Hypocalcaemia D. Hypernatremia

A (is correct: The client who is taking lithium needs an adequate intake of sodium and fluid to prevent the development of lithium toxicity.)

A patient with emphysema is prescribed beclomethasone. Which of the following side effects should the nurse instruct the patient about in the discharge instructions? (select all that apply) A. Cough B. Fatigue C. Dry mouth D. Oral candidiasis E. Hoarseness

A, C, D, E ( Common side effects of beclomethasone and other inhaled corticosteroids include dry mouth, cough, hoarseness, sore throat, nausea, and upset stomach. Local immunosuppression can cause oral candidiasis)

2) when a nurse is administering fluoxetine (Prozac) for the treatment of depression what should the nurse assess for? (select all that apply) A)increased suicidal ideations in young adults? B)respiratory depression C)serotonin syndrome D)Hypertensive crisis E)Monitor ECG

A,C,D (with this drug there is a increase in suicidal ideations in children adolescents and young adults. serotonin syndrome is a side effect of this drug characterized by hypertensive crisis.)

A nurse is admitting a toddler to the hospital after an acetaminophen overdose. Which of the following medications should the nurse anticipate administering to this client? A Acetylcysteine B Narcan C Flumazenil D Naltrexone

A. Acetylcysteine (Acetylcysteine is the antidote for acetaminophen. Narcan is the antidote for opioids. Flumazenil is the antidote for diazepam. Naltrexone is used to treat symptoms of alcohol and opiate withdrawal.)

Question 2: You are working with a 23-year-old patient who has a history of suicide attempts and depression. He was prescribed Fluoxetine (Prozac) a week ago and is back at the clinic. During the assessment he explains that his depression has not changed, and that he has started drinking lately (in moderation) to help cope. How should the nurse respond? A Explain to the patient that he cannot drink alcohol with Fluoxetine (even in moderation) because it can cause serious side effects. B Call the provider and recommend discontinuing this medication. C Explain to the patient that the medication takes up to 2 weeks to take effect. D Explain the risks of drinking alcohol with this medication and that the medication takes 2 weeks to take effect.

Answer: B (Fluoxetine should not have been prescribed for this patient because he has a history of attempted suicides. Although drinking alcohol can enhance sedation, it is still okay to drink alcohol as long as it is in moderation. Explaining that the medication takes 2 weeks to take effect is a true statement, but his is not the best choice.)

A manic patient has been taking lithium for 9 months. When the patient's serum laboratory results are complete, the nurse should compare the patient's lithium levels to what therapeutic range? A. 0.2-0.8 mEq/L B. 0.6-1.2 mEq/L C. 1.2-2 mEq/L D. 2.4-3.2 mEq/L

B

A patient has the flu and is concerned about their fever of 103 degrees F. Which medication would be appropriate to reduce the fever? a. aspirin b. acetaminophen c. indomethacin d. naproxen

B

(1) A nurse is caring for a client who has been in the PACU for more than 1 hour and is difficult to arouse. The nurse should anticipate which of the following medication prescriptions? A. Pentazocine (Talwin) B. Naloxone (narcan) C. Naltrexone (Trexan) D. Butorphanol (Stadol)

B (Naloxone displaces opiate medications from receptor sites, reversing the respiratory depression, sedation, hypertension, and analgesia opiates cause.)

The nurse is reviewing the laboratory report with the client's lithium level prior to administrating the 1700 hours dose. The lithium level is 1.8mEq/L. The nurse should: A. administer the 1700 hours dose of lithium B. hold the 1700 hours dose of lithium C. give the client 240 mL of water with the lithium D. give the lithium after the client's supper

B (Rationale: the nurse should hold the 1700 hours dose of lithium because a level of 1.8 mEq can cause adverse reactions. the nurse should report this lithium level to the health care provider and monitor the patient for signs of lithium toxicity.)

2. A nurse is providing instructions to a client who has a new prescription for albuterol and beclomethasone inhalers for the control of asthma. which of the following instructions should the nurse include in the teaching? a.) Take the albuterol at the same time each day. b.) Administer the albuterol inhaler prior to using the beclomethasone inhaler. c.) Use beclomethasone if experiencing an acute episode. d.) Avoid shaking the beclomethasone before use.

B (When a client is prescribed an inhaled beta 2-agonist (such as albuterol) and an inhaled glucocorticoid (such as betomethasone) the client should take the beta 2-agonist first, it promotes bronchodilation and enhances absorption of the glucocorticoid.)

2. Walter, teenage patient is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs? a. Lungs b. Liver c. Kidney d. Adrenal Glands

B (Acetaminophen is extensively metabolized by pathways in the liver. Toxic doses of acetaminophen deplete hepatic glutathione, resulting in accumulation of the intermediate agent, quinine, which leads to hepatic necrosis. Prolonged use of acetaminophen may result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.)

An alert and oriented elderly patient is prescribed oral morphine sulphate for acute pain management. The patient is on bed rest and is NPO except for meds. The nurse is MOST concerned about which side effect of oral morphine sulfate? A) Dizziness B) Constipation C) Nausea D) Hypertension

B (Constipation Opioid analgesics commonly cause constipation, especially in the elderly. Bed rest and NPO are also contributing factors for constipation. Nausea is a side effect, but this can be medicated. The nurse would be most concerned about addressing the side effects of constipation, then nausea. Opioids can cause nausea and dizziness, but hypertension is not a side effect.)

The nurse is reviewing the laboratory report with the client's lithium level prior to administrating the 1700 hours dose. The lithium level is 1.8mEq/L. The nurse should: A. administer the 1700 hours dose of lithium B. hold the 1700 hours dose of lithium C. give the client 240 mL of water with the lithium D. give the lithium after the client's supper

B (Rationale: the nurse should hold the 1700 hours dose of lithium because a level of 1.8 mEq can cause adverse reactions. the nurse should report this lithium level to the health care provider and monitor the patient for signs of lithium toxicity.)

Nurse if providing teaching about the asthma medication that has been prescribed. What statement by the patient indicates the need for more teaching? A "I'll take montelukast (singulair) pill before I work out so I can worry less about an asthma attack while working out B "Since I'm quitting smoking, I'm glad I'll have my coffee to look forward to every morning" C "I'll keep my albuterol with me at all time, and only use it if I have an asthma attack" D "I'm glad I changed from a beta-blocker to an arb!"

B (The chance of excessive cns and cardiac simulations goes up with asthma medications if the patient drinks caffeine.)

You are caring for a client with bipolar disorder you know they need further education in regards to use of lithium carbonate when... A.They state they will be sure to drink 8 to 12 glasses of water per day. B. Will cut back their sodium intake. C. Will avoid using the sauna when they swim at the gym. D. Will use birth control

B. (Loss of salt leads to an increased risk of adverse effects while taking lithium carbonate so a low sodium diet would not be advised. Maintaining adequate hydration, avoiding excessive sweating to avoid salt loss, and use of birth control while are all appropriate while taking lithium carbonate.)

A woman begins using an albuterol inhaler and a beclomethasone inhaler for her asthma. Which statement by the client indicates further teaching is necessary? A) I use the albuterol inhaler first. After 5-10 minutes I use my beclomethasone inhaler. B) I should rinse my mouth with warm tap water after using my inhalers. C) I use my albuterol inhaler first then immediately use my beclomethasone inhaler. D) I can only use my albuterol inhaler when I am having an acute asthma attack.

C ( the client should wait 5-10 mins after using albuterol to allow for it to open the constricted airways so the corticosteroid inhaler can be effective.)

2.) A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? a.) promote bronchodilation b.) act as an expectorant c.) have an anti-inflammatory effect d.) prevent development of respiratory infections

C (Corticosteroids have an ant-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.)

1.) When assessing the intensity of the pain, the nurse should: A) Ask about what precipitates the pain B) Question the client about the location of the pain C) Offer the client a pain scale to objectify the information D) Use open-ended questions to find out about the sensation

C (Descriptive scales are a more objective means of measuring pain intensity. A. Asking the client what precipitates the pain does not assess intensity, but rather is an assessment of the pain pattern. B. Asking the client about the location of pain does not assess the intensity of the client's pain. D. To determine the quality of the client's pain, the nurse may ask open-ended questions to find out about the sensation experienced.)

2. For an overdose of morphine sulfate, which drug should the nurse have on hand as an antidote? A. phenytoin (Dilantin) B. tramadol (Ultram) C. naloxone (Narcan) D. atropine sulfate (Atropine)

C (Naloxone (Narcan) is an opioid antagonist (blocks receptors. It counteracts the overdose. However, in conditions of extreme pain, Narcan should be given in small increments to avoid a complete loss of pain control. )

The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should: A) Check Respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression. B) Check respirations in 30 minutes because the effects of morphine will have worn off by then. C) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone D) Monitor respirations each time the client receives morphine sulfate 10 mg I.M.

C (Rationale: The nurse should monitor the clients respirations closely for 4 to 6 hours because naloxone has a shorter duration of action than opioids. The client may need repeated doses of naloxone to prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the clients respiration's is necessary. )

2. A nurse is reinforcing teaching with a client prescribed lithium (Eskalith). Which of the following statements indicates a need for further teaching? A. "I should take my medication with meals" B. "I can take Tylenol for headaches" C. "I need to limit my salt intake with this medication" D. "I should feel better in about 2-3 weeks"

C (Lithium should be taken with meals, Tylenol is generally safe for use with lithium, and the effects of lithium begin in 5-7 days, and full therapeutic affects may take 2-3 weeks to develop. C is correct because the nurse should encourage the client to maintain adequate dietary intake of sodium because decreased levels can result in lithium toxicity.)

A 25-year-old female was recently diagnosed with Bipolar disorder. Which of the following statements would indicate to the nurse that the patient needs more education? a. "The doctor is going to prescribe me a low dose of Lithium first, and may increase the dose if he feels it's needed" b. "I will need to have my lithium levels checked periodically to make sure my levels don't get too high." c. "I only have to take Lithium for a few weeks until my symptoms subside" d. "Lithium is going to help treat my manic episodes."

C (Rationale: Similar to an antibiotic, it is a common mistake for people to think that once the symptoms go away the medication does not need to be taken anymore. However, for a full therapeutic effect, medications should be taken for the entire duration that they are prescribed.)

2. A client with chronic schizophrenia is receiving clozapine. Which of the following should a nurse be most concerned with monitoring? A. Sodium B. Potassium C. White blood cell count D. Hemoglobin and hematocrit

C (clozapine has been known to cause agranulocytosis)

The nurse is caring for a patient who is taking Mylanta to treat GERD and requires pH testing. The minimal acceptable gastric pH level is A. 1.5 B. 4.0 C. 3.5 D. 3.0

C (pH testing is used to evaluate the quantity, frequency and duration of acid-reflux episodes. The minimal acceptable pH with antacid therapy is 3.5.)

A 24 year old man with asthma has just been prescribed an albuterol inhaler as needed. The nurse reviewing the chart is concerned about this prescription noting the patient has a diagnosis of what condition? a. Cushing's b. Hypotension c. cardiac dysrhythmia d. sleep apnea

C( Albuterol is contraindicated with the presence of an abnormal heart beat because it increases the heart rate.)

1.) When preparing the teaching plan for a client who is to start clozapine, which information is correct to include? a.) description of akathisia and drug-induced parkinsonism b.) measures to relieve episodes of diarrhea c.) the importance of reporting insomnia d.) an emphasis on the need for weekly blood tests

D (Clozapine is associated with agranulocytosis. Therefore, the nurse must instruct the client about the need for weekly blood tests to monitor for this adverse effect.)

2. A nurse is caring for a critical burn patient. The patient is suffering from intense pain and requires medication. The nurse should expect the physician to prescribe which of the following? A. Fentanyl patch B. Hydromorphone, intranasal C. Oxycodone via nasogastric tube D. Morphine sulfate, IV

D (Pain management of a burn patient should be through the use of IV opioids, typically morphine. )

1. A nurse is providing discharge teaching to a client who has a new prescription for Clozapine. Which of the following statements should the nurse include in the teaching? a. "You should have a high-carbohydrate snack between meals and at bedtime." b. "You are likely to develop hand tremors if you take this medication for a long period of time." c. "You may experience temporary numbness of your mouth after each dose." d. "You should have your white blood cell count monitored every week."

D (Due to the risk for fatal agranulocytosis, weekly monitoring of the client's WBC count is recommended. It is not appropriate to increase carbohydrate intake due to increased risk of developing DM. Clozapine has a low risk for hand tremors and it does not cause temporary numbing of the mouth.)

A man has an order for morphine sulfate 2 mg intravenously every 2 hours following a cholecystectomy. the patient has a history of IV drug abuse. He reports that his pain is 7 out of 10 (with 10 being the worst) and requests the morphine every hour. what is the nurse's appropriate response? a. to instruct him about possible adverse effects b. to tell him that you can administer the drug only every 2 hours c. to use distraction techniques to help him forget his pain d. to notify the surgeon of his request

D (Pain is what the patient says it is. The nurse should notify the surgeon of the inability to control the patient's pain. People who are narcotic tolerant often require additional opioids to manage the pain associated with surgery. Distraction should not be used to avoid administration of medication in patients in pain.)

1. A client is ordered to receive a high dose of a corticosteroid IV. Which action should the nurse anticipate to include in the client's plan of care? A. Observe the client for hypotension. B. Increase the client's oral fluid intake. C. Restrict the client's potassium intake. D. Monitor the client for hyperglycemia.

D (corticosteroid have a side effect of causing hyperglycemia)

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following indicates that the client is using the MDI correctly? Select all that apply. A The inhaler is held upright B The head is tilted down while inhaling the medicine C The client waits 5 minutes between puffs D The client rinses the mouth with water following administration E The client lies supine for 15 minutes following administration

a, d (The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1-2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely be able to breathe more freely if sitting upright.)

A patient in severe respiratory distress is prescribed continuous albuterol nebulizers. Which of the following side effects should the nurse expect? Select all that apply. a) Dizziness b) Urticaria c) Hyperkalemia d) Tachycardia e) Tremors

a, d, e (Dizziness, tachycardia, and tremors are side effects the nurse should be watching for on this patient.)

The health care provider orders ipratropium bromide (Atrovent), albuterol (Proventil), and beclomethasone (Vanceril) inhalers for a client. What is the nurse's best action? a. Question the order; three inhalers should not be given at one time. b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed by beclomethasone several minutes later. c. Administer each inhaler at 30-minute intervals. d. Administer beclomethasone first, wait 2 minutes, and administer ipratropium bromide, followed by the albuterol several minutes later.

b (Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed by beclomethasone several minutes later.)

1. Which of the following situations will cause the nurse to fill an incident report. (a)administering morphine sulfate to a postoperative patient who rates pain of 7 on a pain scale of 0-10 (b)administering acetylcysteine to a patient admitted with acetaminophen overdose (c)administering morphine sulfate to a patient whose respiratory rate is 8 breaths per minute (d)monitoring oxygen saturation on patient on patient controlled analgesics (PCA) pump

c (Respiratory rate is too low)

NCLEX Questions Exam #3 After administering naloxone (Narcan), an opioid antagonist, the nurse should monitor the client carefully for which of the following? A Cerebral edema B Kidney failure C Seizure activity D Respiratory depression

d (After administering naloxone, the nurse should monitor the client's respiratory statues carefully because the drug is short acting and respiratory depression may reoccur after its effects wear off. Cerebral edema, kidney failure, and seizure activity are not directly related to opioid overdose or naloxone therapy.)

The provider orders lactulose for a patient with hepatic encephalopathy. Which of the following assessment findings indicates to the nurse that this medication has been effective? a Relief of abdominal pain b Relief of constipation c Decreased liver enzymes d Decreased ammonia levels

d (Decreased ammonia levels Rationale: Hepatic encephalopathy is a complication of liver failure and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract and also has a laxative effect that helps remove it from the body as stool. This lowers ammonia levels in the body and can reduce symptoms of hepatic encephalopathy)