Question

A nurse is administering diazepam to a client who is having a colonoscopy. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Ensure flumazenil is available to administer for toxicity management.

Rationale :

🔷 Diazepam is a benzodiazepine used for moderate sedation, anxiolysis, and amnesia during procedures like colonoscopy.

🔷 Benzodiazepines can cause respiratory depression and excessive sedation, especially when combined with opioids.

🔷 Flumazenil is the specific benzodiazepine antagonist used to reverse sedation/toxicity.

🔷 Having the reversal agent immediately available supports rapid response if the client becomes overly sedated or hypoventilates.

🔷 This is a key safety action in procedural sedation to protect airway and ventilation.

Monitor the client for an increase in blood pressure.

🔷Diazepam more commonly causes hypotension rather than hypertension, especially with sedation.

🔷The priority monitoring is respiratory status and level of consciousness.

Expect the client to become unconscious within 30 seconds.

🔷Diazepam provides sedation but does not reliably cause immediate unconsciousness, and onset depends on route/dose.

🔷The goal is usually conscious/moderate sedation, not rapid unconsciousness.

Measure the capnography level every hour until the client is awake and oriented.

🔷During sedation, respiratory monitoring must be continuous or very frequent, not hourly.

🔷Hourly checks are too infrequent for safe procedural sedation monitoring.

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Answer 2

Correct Answers:

Taking a stool softener daily will be needed.

Rationale :

💎 Fentanyl is a potent opioid analgesic commonly used for chronic severe pain, including end-of-life comfort.

💎 Opioids decrease GI motility and almost always cause constipation, which does not resolve with tolerance.

💎 A daily bowel regimen (often a stool softener plus stimulant laxative) is a standard preventive measure.

💎 Preventing constipation improves comfort and reduces complications like fecal impaction.

💎 Teaching should emphasize routine bowel management as part of safe opioid patch use.

Respiratory depression…need for at-home nefazodone prescription.

💎Nefazodone is an antidepressant and is not used to manage opioid respiratory depression.

💎Respiratory depression requires urgent assessment and may require naloxone, not nefazodone.

Removing the patch will immediately reverse adverse effects.

💎Fentanyl continues to absorb from the skin even after removal due to a skin depot effect, so effects can persist.

💎Removal helps but does not produce immediate reversal.

An increase in urinary output should be expected.

💎Opioids can cause urinary retention, not increased output.

💎Expected teaching focuses on constipation, sedation, and respiratory depression monitoring.

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Answer 3

Correct Answers:

Atropine

Rationale :

🟣 A cholinergic crisis occurs from excess acetylcholine, often due to too much anticholinesterase medication.

🟣 This leads to muscarinic effects such as bradycardia, bronchospasm, bronchorrhea, salivation, diarrhea, and miosis.

🟣 Atropine is an anticholinergic that blocks muscarinic receptors and helps reverse life-threatening secretions and bradycardia.

🟣 Treating cholinergic crisis focuses on stabilizing the airway and reducing dangerous parasympathetic overstimulation.

🟣 Atropine is the correct medication in this scenario to counteract muscarinic toxicity.

Potassium iodide

🟣Potassium iodide is used for thyroid protection or certain thyroid conditions, not cholinergic toxicity.

🟣It does not counteract acetylcholine excess.

Glucagon

🟣Glucagon is used for severe hypoglycemia or beta-blocker overdose support, not cholinergic crisis.

🟣It does not reverse muscarinic symptoms.

Protamine

🟣Protamine is the antidote for heparin, not for cholinergic crisis.

🟣It has no role in reversing acetylcholine excess.

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Answer 4

Correct Answers:

"I should sit up for 30 minutes after taking the risedronate."

Rationale :

🔷 Risedronate is a bisphosphonate used to reduce bone loss and fracture risk in osteoporosis.

🔷 It can cause esophagitis and esophageal irritation if it refluxes or remains in the esophagus.

🔷 Remaining upright for at least 30 minutes reduces reflux risk and helps the tablet move into the stomach.

🔷 The medication should be taken with plain water on an empty stomach to improve absorption.

🔷 Correct positioning and timing are critical to prevent GI injury and ensure effective therapy.

“I will drink a glass of milk when I take the risedronate.”

🔷Calcium in milk binds bisphosphonates and reduces absorption.

🔷It should be taken with plain water only.

“I will take the risedronate 15 minutes after my evening meal.”

🔷Food significantly decreases absorption, so it should be taken before eating.

🔷It is usually taken in the morning on an empty stomach unless otherwise prescribed.

“I should take an antacid with the risedronate to avoid nausea.”

🔷Antacids (calcium, magnesium, aluminum) can interfere with absorption and should not be taken at the same time.

🔷Any GI management should follow provider guidance and spacing instructions.

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Answer 5

Correct Answers:

"I will take the patch off right after my evening meal."

Rationale :

💎 Nitroglycerin patches prevent angina by producing vasodilation and decreasing myocardial oxygen demand.

💎 Continuous nitrate exposure causes tolerance, so clients need a daily nitrate-free interval (commonly 10–12 hours).

💎 Removing the patch in the evening is a common schedule to provide that nitrate-free period overnight.

💎 This strategy helps the medication remain effective for daytime activity when angina risk may be higher.

💎 Correct use includes rotating sites and monitoring for headache, dizziness, and hypotension.

“I should apply a patch every 5 minutes if I develop chest pain.”

💎Patches are not used for rapid relief; they are for prevention and have slower onset.

💎Acute chest pain is treated with sublingual nitroglycerin and emergency evaluation if not relieved.

“I will leave the patch off at least 1 day each week.”

💎The nitrate-free interval should occur every day, not weekly, to prevent tolerance.

💎Weekly removal is insufficient and can make therapy ineffective.

“I should discard the used patch by flushing it down the toilet.”

💎Flushing medications is generally discouraged unless specifically instructed, and patches still contain drug residue.

💎Used patches should be folded sticky sides together and discarded safely per facility or product guidance to prevent accidental exposure.

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Answer 6

Correct Answers:

Check the client's blood glucose.

Rationale :

🔷 The nurse’s first priority after a medication error is client safety using immediate assessment.

🔷 Metformin can lower blood glucose, so checking a baseline blood glucose identifies any urgent risk of hypoglycemia.

🔷 Rapid assessment guides what actions are needed next (monitoring frequency, treatment, provider notification).

🔷 This action follows the nursing priority of assess first before reporting/documentation steps.

🔷 Prompt assessment also provides objective data to communicate accurately to the provider and charge nurse.

Report the incident to the charge nurse.

🔷Reporting is required, but the immediate priority is assessing the client for harm.

🔷 Client stability must be verified before administrative steps.

Notify the provider.

🔷The provider must be notified, but the nurse should first collect essential assessment data (like blood glucose).

🔷Providing current findings supports timely and appropriate provider orders.

Fill out an incident report.

🔷An incident report is completed after the client is assessed and appropriate notifications are made.

🔷 Documentation does not take priority over immediate client assessment.

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Answer 7

Correct Answers:

"Report yellowing of the skin."

Rationale :

💎 Famotidine is an H2 receptor blocker that reduces gastric acid secretion, promoting ulcer healing and symptom relief.

💎 A serious adverse effect to report is jaundice (yellowing of skin/eyes), which can indicate hepatic dysfunction.

💎 Teaching should emphasize reporting unusual symptoms promptly because early detection prevents complications.

💎 Famotidine is not typically taken only short-term “until discomfort stops,” because ulcers need adequate healing time.

💎 Reporting jaundice is a safety-focused instruction aligned with monitoring for significant medication reactions.

“Take the medication on an empty stomach for full effectiveness.”

💎Famotidine may be taken with or without food, so empty stomach is not required for effectiveness.

💎Timing may be individualized (often bedtime), but strict fasting is unnecessary.

“You may discontinue this medication when stomach discomfort subsides.”

💎Symptoms can improve before the ulcer heals, so stopping early increases relapse/complication risk.

💎The client should follow the prescribed duration and provider guidance.

“You will be taking this medication for 2 weeks.”

💎Treatment duration varies based on ulcer severity and provider plan and is not automatically limited to two weeks.

💎It may be prescribed longer for healing and recurrence prevention.

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Answer 8

Correct Answers:

The client rates pain as 3 on a scale of 0 to 10.

Rationale :

🟣 The most accurate measure of pain relief is the client’s self-reported pain score, because pain is subjective.

🟣 Morphine effectiveness is best evaluated by comparing the current pain rating to the pre-medication rating.

🟣 A pain score of 3/10 reflects improved comfort and often meets functional pain goals for many clients.

🟣 Objective signs (vitals, resting) can occur even when pain persists, so they are not as reliable as self-report.

🟣 Using the client’s rating supports safe reassessment and appropriate future dosing decisions.

The client’s vital signs are within normal limits.

🟣Normal vital signs do not confirm pain relief because clients can have pain without abnormal VS.

🟣VS trends are supportive data but not the best indicator.

The client has not requested additional medication.

🟣A client may avoid requesting medication due to fear of opioids, sedation, or misunderstanding.

🟣Lack of request does not reliably equal adequate pain control.

The client is resting comfortably with eyes closed.

🟣Morphine can cause sedation, so eyes closed may reflect sleepiness rather than true analgesia.

🟣The best measure remains the client’s reported pain level.

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Answer 9

Correct Answers:

"I will remove the patch after 14 hours."

Rationale :

🔷 Nitroglycerin patches are used for angina prevention, not immediate relief.

🔷 Clients must have a daily nitrate-free interval to prevent tolerance, commonly by removing the patch after about 12–14 hours.

🔷 Removing it after 14 hours provides an off-time that helps the medication remain effective.

🔷 Proper use includes rotating sites, applying to clean dry skin, and avoiding heat sources that increase absorption.

🔷 This statement demonstrates correct understanding of scheduled removal for tolerance prevention.

“I can apply the patch to a chest area that has hair.”

🔷Hair can prevent proper adhesion and lead to inconsistent absorption.

🔷The patch should be applied to hairless skin or hair should be clipped (not shaved) if needed.

“I can take this medication while using an erectile dysfunction product.”

🔷Nitroglycerin with PDE5 inhibitors can cause life-threatening hypotension.

🔷This combination is contraindicated.

“I need to apply a new patch to the same area every day.”

🔷Sites should be rotated to prevent skin irritation and ensure consistent absorption.

🔷Reusing the same area increases risk of dermatitis.

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Answer 10

Correct Answers:

Presence of U-waves

Rationale :

💎 Furosemide is a loop diuretic that increases urinary potassium loss, raising risk for hypokalemia.

💎 A classic ECG change in hypokalemia is the appearance of U-waves, often after the T-wave.

💎 Hypokalemia also increases risk for dysrhythmias due to altered myocardial repolarization.

💎 Recognizing U-waves early supports prompt electrolyte correction and safer cardiac function.

💎 Monitoring potassium is essential during IV diuretic therapy in heart failure clients.

Tall, tented T-waves

💎This finding is associated with hyperkalemia, not hypokalemia.

💎Hyperkalemia produces peaked T-waves and can rapidly become life-threatening.

Widened QRS complex

💎QRS widening is more typical of severe hyperkalemia.

💎Hypokalemia more commonly shows flattened T-waves and U-waves.

ST elevation

💎ST elevation is associated with myocardial injury/ischemia patterns, not a typical potassium-loss finding.

💎Hypokalemia more often causes ST depression and U-waves.

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QLexNursing

1 :
A nurse is administering diazepam to a client who is having a colonoscopy. Which of the following actions should the nurse take?

2 :
A nurse is preparing medication instructions for a client who is receiving end-of-life care and their family. The client has a prescription for fentanyl patches. Which of the following information regarding the manifestations and use of fentanyl should the nurse include in the instructions?

3 :
A nurse in an emergency department is caring for a client who has myasthenia gravis and is in a cholinergic crisis. Which of the following medications should the nurse plan to administer?

4 :
A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

5 :
A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramide. Which of the following actions should the nurse take first?

7 :
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for famotidine. Which of the following instructions should the nurse include?

8 :
A nurse is assessing a client 1 hr after administering morphine for pain. Which of the following findings should the nurse identify as the best indication that the morphine has been effective?

9 :
A nurse is teaching about self-administration of transdermal medication with a client who has a new prescription for nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

10 :
A nurse is reviewing the ECG of a client who is receiving IV furosemide for heart failure. The nurse should identify which of the following findings as an indication of hypokalemia?

QLexNursing

1 : A nurse is administering diazepam to a client who is having a colonoscopy. Which of the following actions should the nurse take?

2 : A nurse is preparing medication instructions for a client who is receiving end-of-life care and their family. The client has a prescription for fentanyl patches. Which of the following information regarding the manifestations and use of fentanyl should the nurse include in the instructions?

3 : A nurse in an emergency department is caring for a client who has myasthenia gravis and is in a cholinergic crisis. Which of the following medications should the nurse plan to administer?

4 : A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

5 : A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramide. Which of the following actions should the nurse take first?

7 : A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for famotidine. Which of the following instructions should the nurse include?

8 : A nurse is assessing a client 1 hr after administering morphine for pain. Which of the following findings should the nurse identify as the best indication that the morphine has been effective?

9 : A nurse is teaching about self-administration of transdermal medication with a client who has a new prescription for nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

10 : A nurse is reviewing the ECG of a client who is receiving IV furosemide for heart failure. The nurse should identify which of the following findings as an indication of hypokalemia?

1 :
A nurse is administering diazepam to a client who is having a colonoscopy. Which of the following actions should the nurse take?

2 :
A nurse is preparing medication instructions for a client who is receiving end-of-life care and their family. The client has a prescription for fentanyl patches. Which of the following information regarding the manifestations and use of fentanyl should the nurse include in the instructions?

3 :
A nurse in an emergency department is caring for a client who has myasthenia gravis and is in a cholinergic crisis. Which of the following medications should the nurse plan to administer?

4 :
A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

5 :
A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramide. Which of the following actions should the nurse take first?

7 :
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for famotidine. Which of the following instructions should the nurse include?

8 :
A nurse is assessing a client 1 hr after administering morphine for pain. Which of the following findings should the nurse identify as the best indication that the morphine has been effective?

9 :
A nurse is teaching about self-administration of transdermal medication with a client who has a new prescription for nitroglycerin. Which of the following client statements indicates an understanding of the teaching?

10 :
A nurse is reviewing the ECG of a client who is receiving IV furosemide for heart failure. The nurse should identify which of the following findings as an indication of hypokalemia?