R 2510 Exam #3 Version 2 - (12) Adverse Defects Interactions, and Contraindications: Identifying Venipuncture Sites Airway Management: Medications of Hypoxia C

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Sample questions from R 2510 Exam #3 Version 2 - (12) Adverse Defects Interactions, and Contraindications: Identifying Venipuncture Sites Airway Management: Medications of Hypoxia C

This material has 75 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 67-year-old client with COPD becomes drowsy after receiving IV morphine for a painful rib fracture. The respiratory rate is 8/min, SpO2 is 84% on 2 L/min by nasal cannula, and the client is difficult to arouse. Which action should the nurse take first?

   • A.Administer the prescribed PRN dose of albuterol.
   • B.Increase oxygen to 6 L/min by nasal cannula and reassess in 15 minutes.
   • C.Obtain an arterial blood gas before changing the treatment plan.
   • D.Stop the opioid infusion and support ventilation while summoning the rapid response team.

   Rationale: The bradypnea, reduced responsiveness, and hypoxemia suggest opioid-induced respiratory depression, so stopping the opioid and immediately supporting ventilation address the life threat. Increasing oxygen alone may conceal worsening hypoventilation and does not restore ventilation. Albuterol treats bronchospasm, which is not indicated by these cues, and obtaining an arterial blood gas must not delay airway and breathing support.

2. 2.Refer to the client's chart. Which actions should the nurse take now for this 74-year-old client in the medical unit? Select all that apply.

   • A.Stop the heparin infusion and notify the provider about the platelet trend and new bleeding.
   • B.Prepare to administer protamine sulfate if prescribed.
   • C.Administer the next dose of warfarin to maintain anticoagulation.
   • D.Assess for additional bleeding and verify the most recent medication and infusion history.
   • E.Apply firm pressure to the oozing IV site and reassess the site.
   • F.Continue the infusion and repeat the platelet count at the next scheduled draw.

   Rationale: The platelet count fell from 214,000 to 82,000/mm3 during heparin therapy, with new IV-site oozing, so the nurse should stop heparin, promptly notify the provider, assess for bleeding, and apply pressure to the site. Protamine may be prescribed to reverse heparin, but the nurse should not administer it without an order. Continuing heparin or giving warfarin before evaluating suspected heparin-induced thrombocytopenia could worsen harm.

3. 3.During a home visit, a 58-year-old client with heart failure reports taking digoxin and furosemide and now has nausea, blurred yellow vision, and weakness. The apical pulse is 52/min and irregular; potassium is 2.9 mEq/L. Which action is the priority?

   • A.Hold digoxin and contact the prescribing clinician promptly.
   • B.Encourage a potassium-rich meal and reassess the pulse tomorrow.
   • C.Have the client take digoxin with food to reduce gastrointestinal effects.
   • D.Give the scheduled furosemide to reduce the risk of fluid overload.

   Rationale: Bradycardia, visual changes, and nausea with hypokalemia suggest digoxin toxicity, and the next dose should be withheld while the clinician is contacted. Furosemide can worsen potassium depletion and should not be given without resolving the urgent concern. Dietary potassium is not an immediate or reliable treatment for this presentation, and taking digoxin with food does not address toxicity.

4. 4.At change of shift in a pediatric clinic, a 4-year-old with asthma has audible wheezing, intercostal retractions, and an SpO2 of 91% on room air. The caregiver reports giving a second dose of an over-the-counter cough medicine containing dextromethorphan 20 minutes ago. Which action should the nurse take first?

   • A.Teach the caregiver to use a long-acting controller inhaler for immediate relief.
   • B.Assess airway and breathing, initiate the prescribed rescue bronchodilator, and provide oxygen as indicated.
   • C.Delay treatment until the provider evaluates whether the cough medicine interacted with the asthma medication.
   • D.Ask the caregiver to give another dose of the cough medicine after the bronchodilator.

   Answer and rationale are in the full material.

5. 5.In an outpatient infusion center, a 33-year-old client with a left-arm dialysis arteriovenous fistula needs blood drawn for a medication level. The right arm has a functioning peripheral IV and mild edema after recent mastectomy with lymph-node dissection. Which action should the nurse take?

   • A.Draw the specimen from the fistula arm proximal to the access.
   • B.Use the right arm because a peripheral IV is less restrictive than a fistula.
   • C.Request guidance on an alternate approved site, such as a suitable hand vein, and avoid both arms' restricted areas.
   • D.Draw the specimen from the right antecubital vein after temporarily stopping the IV.

   Answer and rationale are in the full material.