A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Deviation of the tongue from midline

Loss of peripheral vision

Disequilibrium with movement

Inability to smell

Answer and Explanation

The Correct Answer is C

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

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Correct Answer is D

Explanation

A low potassium level (hypokalemia) can increase the risk for digoxin toxicity because it enhances the binding of digoxin to cardiac cells and increases its effects on cardiac contractility and electrical conduction. The nurse should monitor the client's potassium level and administer potassium supplements as prescribed if needed. The other electrolytes are not directly related to digoxin toxicity.

A. Protamine sulfate B. Acetylcysteine C. Vitamin K D. Flumazenil

Correct Answer is A

Explanation

Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.

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A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

Correct Answer is D

Explanation

A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?

Correct Answer is A

Explanation

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