NUR 213 Health Exam

Correct Answer:

D) Naloxone

Explanation:

• Butorphanol is an opioid agonist-antagonist analgesic used for pain relief during labor. It can cause respiratory depression in both the mother and newborn.


• Naloxone (Narcan) is an opioid antagonist that reverses the effects of opioids, including respiratory depression and sedation.


• If respiratory depression occurs in the mother or newborn, Naloxone should be administered to reverse the opioid effects.

Why the Other Options Are Incorrect:

A) Protamine

• Protamine sulfate is the antidote for heparin overdose and has no effect on opioids.

B) Diphenhydramine

• Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions and motion sickness.


• It does not reverse opioid effects.

C) Atropine

• Atropine is an anticholinergic medication used to treat bradycardia and reduce secretions before surgery.


• It does not counteract opioid-induced respiratory depression.

Key Takeaway:

Naloxone is the go-to antidote for opioid-induced respiratory depression and should always be available when administering opioids like butorphanol.

Correct Answers: B, C, D, E. 

✅ Inspect the sacrum for blanching

✅ Frequent turning and positioning

✅ Optimizing nutrition

✅ Frequent skin assessments

Correct Answers and Explanations:

Inspect the sacrum for blanching

Inspecting the sacrum for blanching is crucial in the early detection of pressure injuries. Blanching refers to the temporary whitening of the skin when pressure is applied, indicating adequate blood flow. If an area does not blanch, it may suggest the beginning of a pressure injury. Early identification allows for timely intervention, such as repositioning and pressure relief, to prevent further skin breakdown.

Frequent turning and positioning

Regular repositioning, ideally every two hours, helps redistribute pressure and reduce prolonged compression on bony prominences such as the sacrum, heels, and elbows. This prevents ischemia, which can lead to tissue damage and ulcer formation. Additionally, using pillows or foam wedges to offload pressure points can further reduce the risk of pressure injuries.

Optimizing nutrition

Proper nutrition plays a significant role in skin integrity and wound healing. Protein is essential for tissue repair, while adequate calorie intake ensures that the body has enough energy to maintain healthy skin. Hydration is also critical, as dehydrated skin is more prone to breakdown. Vitamins such as vitamin C and zinc support collagen formation and wound healing, reducing the risk of pressure injuries.

Frequent skin assessments

Regular skin assessments allow early identification of redness, non-blanching areas, or open wounds before they progress into more severe pressure injuries. These assessments should be done at least once per shift, focusing on areas at high risk, such as the sacrum, heels, elbows, and back of the head. If any signs of skin breakdown are noted, immediate interventions such as repositioning, use of barrier creams, and pressure-relieving devices should be implemented.

Incorrect Answer and Explanation:

Maintaining the head of the bed at a 45-degree angle

Keeping the head of the bed at a 45-degree angle increases shear and friction forces, especially on the sacrum and lower back. This can contribute to skin breakdown and pressure injury formation. Instead, the head of the bed should be kept at 30 degrees or lower whenever possible to reduce these forces while still maintaining comfort and preventing aspiration, especially in patients at risk for aspiration pneumonia.

Summary:

To effectively reduce the incidence of pressure injuries in hospitalized clients, nurses should conduct frequent skin assessments, inspect for blanching, reposition the patient regularly, and ensure optimal nutrition and hydration. The head of the bed should not be elevated beyond 30 degrees to prevent increased shear and friction, which can accelerate skin breakdown.

Correct Answer: B. "I will have my teeth cleaned by my dentist in 2 weeks."

Explanation:

Clients with mitral valve replacement, especially those with mechanical valves, are at a higher risk for infective endocarditis (IE) due to the potential for bacterial infection spreading through the bloodstream during dental procedures. To reduce infection risk, clients should wait at least 6 months before undergoing non-urgent dental procedures, and they should take prophylactic antibiotics before any dental work (e.g., cleanings, extractions).

Why the Other Options Are Correct:

A. "I'll be able to carry heavy loads after 6 months of rest." 

Correct statement because lifting heavy objects is restricted for several months post-surgery to allow the sternum and incision to heal properly. Straining can increase cardiac workload.

C. "I must avoid eating foods high in vitamin K, like spinach." 

Correct statement because clients on warfarin (Coumadin) for anticoagulation therapy need to maintain consistent vitamin K intake to avoid fluctuations in INR levels. While they do not have to completely avoid vitamin K-rich foods, they should not make sudden dietary changes that can affect anticoagulation.

D. "I must use an electric razor instead of a straight razor to shave." 

Correct statement because clients on anticoagulants (e.g., warfarin) have an increased risk of bleeding. Using an electric razor reduces the risk of cuts and excessive bleeding compared to a traditional razor.

Key Takeaways:

 Clients with valve replacements need prophylactic antibiotics before dental procedures to prevent infective endocarditis (IE).

Dental work should generally be postponed for at least 6 months post-surgery unless urgent.

Warfarin therapy requires monitoring and dietary consistency regarding vitamin K intake.

Lifting restrictions and bleeding precautions should be followed to prevent complications.

Summary:

The correct answer is B, as the client needs additional teaching about delaying dental procedures and the need for prophylactic antibiotics before any dental work to prevent infective endocarditis (IE).

Correct Answer: B) Maintaining a patent airway

Explanation:

The highest priority for a patient in the PACU is maintaining a patent airway because anesthesia and sedation can depress the respiratory drive and cause airway obstruction. Patients recovering from anesthesia are at risk for hypoventilation, airway obstruction, hypoxia, and aspiration due to decreased muscle tone and protective reflexes. Airway management takes priority over circulation, pain management, and bleeding assessment because without an open airway, oxygenation and perfusion cannot be maintained.

Why the Other Choices Are Incorrect:

A) Assessing for hemorrhage

Hemorrhage is a critical concern, but it is secondary to airway maintenance in the immediate postoperative period. Once the patient is breathing effectively, the nurse can assess for signs of bleeding.

C) Managing the patient's pain

Pain management is important, but it is not more critical than airway maintenance and ensuring the patient is breathing adequately. If a patient is not breathing properly, pain medication could further depress respiration, worsening the situation.

D) Assessing vital signs every 30 minutes

Vital sign monitoring is essential but does not take precedence over ensuring the airway remains open and clear. In the immediate post-op phase, vital signs are assessed more frequently (every 5-15 minutes) until the patient stabilizes.

Key Takeaway:

A patent airway is the top priority in the PACU. Without an open airway, oxygenation and perfusion cannot be sustained, leading to life-threatening complications.

Correct Answer: d. Perform hand hygiene.

Explanation:

Performing hand hygiene is the most important action before any procedure, including dressing changes. Proper hand hygiene reduces the risk of infection by preventing the spread of microorganisms. This is especially critical for a sternal wound, as infections in this area can lead to serious complications such as mediastinitis.

Why the other options are incorrect:

a. Assess vital signs.

Assessing vital signs is important but not the first priority when preparing for a dressing change. Hand hygiene must come first to prevent contamination.

b. Don a mask and gown.

Wearing PPE (such as a mask and gown) may be necessary, but it should be done after performing hand hygiene to avoid contaminating the protective equipment.

c. Gather needed supplies.

Having all necessary supplies ready is essential for efficiency, but touching supplies before cleaning hands can introduce bacteria and increase infection risk.

Summary:

Hand hygiene is the first and most important step before any patient care procedure. It helps prevent infection, ensures patient safety, and follows infection control guidelines.

Correct Answer:

B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

Explanation:

• The priority intervention in an unresponsive, apneic patient is to establish a patent airway.


• A blue, dusky appearance (cyanosis) indicates hypoxia, which is life-threatening.


• Head-tilt, chin-lift or jaw thrust maneuvers help open the airway by repositioning the tongue, which can obstruct breathing.


• If the patient does not begin breathing, manual ventilation with a bag-valve mask (BVM) and supplemental oxygen should be initiated immediately.

Why the Other Choices Are Incorrect:

A) Check the patient's oxygen saturation level, continue to monitor for apnea, and perform a focused assessment.

• Incorrect because immediate action is needed—this is a medical emergency.


• Delaying airway intervention to check oxygen saturation could result in severe hypoxia, brain damage, or cardiac arrest.

C) Assess the arterial pulses, and place the patient in the Trendelenburg position.

• Incorrect because the priority is airway and breathing, not circulation at this moment.


• Trendelenburg (feet elevated) is not an appropriate intervention for respiratory failure and may actually impair breathing further.

D) Reintubate the patient.

• Incorrect because reintubation is not the first step—basic airway maneuvers should be attempted first.


• If the patient does not respond to airway maneuvers and ventilation, then reintubation may be necessary.

Key Takeaway:

In an apneic patient with cyanosis, the immediate priority is to establish a patent airway using the head-tilt, chin-lift or jaw-thrust maneuver to restore breathing.

Correct Answers: 

Apply compression stockings

Ambulate the client early

Encourage client to do active leg exercises

Why These Answers Are Correct:

Apply compression stockings

Compression stockings promote venous return and help prevent blood stasis in the lower extremities, which reduces the risk of deep vein thrombosis (DVT), a major cause of pulmonary embolism (PE).

Ambulate the client early

Early ambulation is one of the most effective ways to prevent venous stasis and blood clot formation. Moving the legs and engaging muscles improves circulation and reduces the likelihood of clot formation.

Encourage client to do active leg exercises

Leg exercises, such as ankle pumps and foot circles, promote circulation in the lower extremities, helping to prevent venous stasis and clot formation.

Why the Other Choices Are Incorrect:

Maintain the head of the bed at 90 degrees

Keeping the head of the bed at 90 degrees (full upright position) is not necessary and may reduce venous return, increasing the risk of DVT. Instead, a semi-Fowler's position (30-45 degrees) is generally preferred for comfort and optimal lung expansion.

Administer aspirin and warfarin

While anticoagulants like warfarin and heparin are commonly used for clot prevention, aspirin is not the primary choice for preventing pulmonary embolism in surgical patients. Additionally, warfarin requires several days to reach therapeutic levels, making it not an immediate intervention post-surgery.

Summary:

To reduce the risk of pulmonary embolism, the nurse should apply compression stockings, encourage early ambulation, and promote active leg exercises. Full upright positioning and aspirin use are not recommended as primary interventions for PE prevention in surgical patients.

Correct Answers:

A. "Until your incision is healed, do not submerge your pacemaker. Only take showers."

B. "Report any pulse rates lower than your pacemaker settings."

E. "Do not lift your left arm above the level of your shoulder for 8 weeks."

Explanation

A. "Until your incision is healed, do not submerge your pacemaker. Only take showers."

Preventing infection is crucial. The client should not submerge the incision in water (e.g., no baths, swimming) until it is completely healed.

B. "Report any pulse rates lower than your pacemaker settings."

The pacemaker is set to maintain a minimum heart rate. If the pulse is below the set rate, this may indicate pacemaker malfunction or battery failure.

E. "Do not lift your left arm above the level of your shoulder for 8 weeks."

Lifting the arm on the side of the pacemaker (usually the left side) too soon can lead to lead dislodgement. The restriction is typically 6-8 weeks post-implantation.

Incorrect Answers

C. "If you feel weak, apply pressure over your generator."

Applying pressure over the pacemaker site is not recommended and does not improve function. If the client feels weak, they should seek medical attention.

D. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)."

Many newer pacemakers are MRI-compatible, but older models may not be. Instead of turning it off, the provider should assess if the pacemaker is safe for MRI or take necessary precautions.

Correct Answer:

B Pantoprazole

Explanation:

Pantoprazole is a proton pump inhibitor (PPI), a class of medications that reduce stomach acid production by blocking the H+/K+ ATPase enzyme in gastric parietal cells. PPIs are commonly prescribed for peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome to promote healing and prevent ulcer recurrence.

Why the Other Options Are Incorrect:

1. Cimetidine – This is an H2 receptor antagonist (H2RA), not a PPI. It works by blocking histamine receptors in the stomach to reduce acid production but is less potent than PPIs.


2. Ranitidine – Another H2 receptor antagonist, previously used for acid suppression but withdrawn from many markets due to safety concerns related to contamination with NDMA, a probable carcinogen.


3. Famotidine – Also an H2 receptor antagonist, which can reduce acid production but is not as effective as PPIs in treating peptic ulcers.

Summary:

The nurse should anticipate the provider ordering Pantoprazole, as it is a proton pump inhibitor (PPI) and is more effective than H2 receptor antagonists in reducing stomach acid and promoting ulcer healing.