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 ["A","C","D"]

Explanation

A. Monitor intake and output every shift: Important for tracking fluid balance and ensuring appropriate hydration and nutritional support.
B. Change the IV tubing every seven (7) days: IV tubing should generally be changed every 24 to 72 hours or as per hospital protocol, not every seven days.
C. Place the solution on an IV pump at the prescribed rate: Ensures accurate administration of TPN and prevents complications associated with over or under-infusion.
D. Monitor blood glucose every one (1) hour: Frequent monitoring is required as TPN can cause fluctuations in blood glucose levels.
E. Weigh the client weekly, first thing in the morning: While weighing the client is important, it is typically done more frequently than weekly to monitor fluid status and nutritional response.

A. Respiratory rate 24/min B. Blood pressure 138/86 mm Hg C. Total urinary output 700 mL in 24 hours D. Weight loss of 4 lb in 24 hours

Correct Answer is D

Explanation

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

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Naxlex Comprehensive Predictor Exams

The client is NPO and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter. Which precautions should the nurse implement? (Select All That Apply)

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

Explanation

The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Correct Answer is D

Explanation

Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

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?

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?