A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Encourage the client to obtain a prescription for a benzodiazepine antagonist.

Instruct the client that it is important to reduce the dose of the medication gradually.

Discuss with the client that there may be a need for additional sleep if the feeling of fatigue is present the next day.

Advise the client to stop taking the medication immediately.

Answer and Explanation

The Correct Answer is B

Rationale

A. Benzodiazepine antagonists, such as flumazenil, are used to reverse the effects of benzodiazepines in cases of overdose or excessive sedation. However, in the context of using temazepam for insomnia, this is not a standard approach.

B. Benzodiazepines like temazepam should not be stopped abruptly, especially if they have been taken regularly. Abrupt cessation can lead to withdrawal symptoms, including rebound insomnia, anxiety, agitation, and potentially seizures in severe cases.

C. This option addresses the symptom of feeling "hungover" or fatigued the next day after taking temazepam. It acknowledges that residual sedation or drowsiness can occur with temazepam use. The nurse can educate the client about the potential for these side effects and suggest allowing for adequate time for sleep to alleviate these symptoms.

D. Stopping temazepam abruptly is not recommended because it can lead to withdrawal symptoms and potentially worsen insomnia. This option does not address the need for tapering off the medication or managing the symptoms effectively.

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Correct Answer is ["A","B","C","D","F"]

Explanation

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.

Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.

Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.

Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.

Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.

A. Replace fluids IV based on intake and output. B. Record the amount of daily wound drainage. C. Turn every 2 hours around the clock from side-to-side. D. Assess skin condition and turgor for breakdown.

Correct Answer is A

Explanation

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.

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A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","F"]

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

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