Archer Review 1b Exam
The emergency department (ED) nurse is caring for a client with acetaminophen toxicity. The nurse
anticipates a prescription for which medication?
A. Acetylcysteine
[85%]
B. Deferoxamine mesylate
[5%]
C. Succimer
[2%]
D. Flumazenil
[7%] - verified answer Explanation
Choice A is correct. Acetylcysteine is given to convert toxic metabolites to nontoxic ones.
Acetaminophen is one of the most commonly used oral analgesics and antipyretics. The maximum
dose for an adult is four grams in a 24-hour period. Toxicity starts after the consumption of seven
grams.
Choices B, C, and D are incorrect. Deferoxamine mesylate is the antidote for iron intoxication.
Succimer is the antidote for lead poisoning. Flumazenil is the antidote for the sedative effect of
benzodiazepines.
Additional Info
Acute hepatic necrosis may result from large ingestion of acetaminophen. Acute hepatotoxicity can
usually be reversed with acetylcysteine, whereas long-term toxicity is more likely to be permanent.
The issue with acetaminophen toxicity is that most cases come from accidental ingestion because
clients are unaware the cold remedies contain acetaminophen. Thus, appropriate education must be
provided to avoid this type of toxicity.
The nurse is caring for several clients in a long-term care facility. Which interventions should the
nurse implement to reduce the risk of injury for these clients? Select all that apply.
A. Avoid administering ibuprofen at night.
[3%]
,B. Secure the call button to the side of the bed.
[32%]
C. Keep the bed in the lowest position.
[38%]
D. Complete a fall risk assessment within 24 hours of admission.
[27%] - verified answer Explanation
Choices B and C are correct. Falls and injuries can be reduced by ensuring the call button are
accessible (Choice B) and within easy reach for the client. The call light can be clipped or secured
when the client is in bed to prevent falling out of reach.
Most clients in long-term facilities need some assistance and are at risk of falls. The nurse must
complete a fall risk assessment at admission or within 2 hours of admission. Setting the bed to the
lowest position (Choice C) would reduce the risk of injury in the event of a fall because such
positioning keeps the patient at a closer distance to the floor.
Choices A and D are incorrect. Evening administration of NSAIDS do not increase the risk of falls. On
the other hand, the nurse should avoid administering diuretics and laxatives before the patient's
sleep to reduce urgent bathroom needs. Having to push for urgent bathroom needs may lead to
falls. The nurse should complete a fall risk assessment upon admission or within 2 hours of
admission to promptly implement fall-prevention interventions for high-risk clients. Waiting 24
hours to complete a fall-risk assessment is inappropriate because a preventable fall may have
already happened.
Additional Info
Universal fall precautions involve
• Monitor the client's activities and behavior as often as possible, preferably every 30 to 60 minutes.
• Teach the client and family about the fall prevention program to become safety partners.
• Remind the client to call for help before getting out of bed or a chair.
• Help the client get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs
before transferring client's.
• Teach clients to use the grab bars when walking in the hall without assistive devices or when using
the bathroom.
• Provide or remind the client to use a walker or cane for
A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an
expected finding due to immobility?
,A. A decrease in bone density
[2%]
B. Loss of short-term memory
[66%]
C. Atelectasis
[10%]
D. High serum calcium level
[21%] - verified answer Explanation
Choice B is correct. Loss of short-term memory is not an expected complication of prolonged
immobility and warrants further assessment. Short-term memory loss may indicate medication
effects, Alzheimer's dementia, or Lewy body dementia, etc.
Choices A, C, and D are incorrect. Decreased bone density (osteoporosis), atelectasis, and
hypercalcemia are all expected due to prolonged immobility.
Risk factors related to mobility can affect every organ system. The musculoskeletal system can
experience contractures, joint ankylosis, and depletion of necessary minerals/loss of bone density.
Hypercalcemia (Choice D) may occur with prolonged immobility. Prolonged immobilization deranges
bone remodeling because of the lack of mechanical stress. This causes an imbalance between bone
formation and bone resorption where resorption exceeds formation. Consequently, there is a net
efflux of calcium from the bone. Respiratory complications such as atelectasis (Choice C) and
pneumonia may occur. Gastrointestinal manifestations (constipation) may occur due to decreased
peristalsis. Immobile individuals are also more prone to orthostatic hypotension, decreased
metabolism, and skin breakdown/decubitus ulceration.
The nurse is assessing a patient in active labor. Her contractions are increasing in frequency as well
as the duration and presenting 5 minutes apart for 60 seconds each with every contraction. The fetal
heart rate begins to slow from 150 to 110 after the decrease starts. Which of the following are
priority nursing actions for this situation?
Select all that apply.
A. Reposition the mother to a supine position
[7%]
B. Administer 100% FiO2 via face mask
[34%]
, C. Notify the healthcare provider
[37%]
D. Prepare for delivery
[21%] - verified answer Explanation
Choices B and C are correct. Late decelerations or dips in the fetal heart rate that occur after a
contraction are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this
sign, she will need to intervene quickly. Administering 100% FiO2 via a face mask is an appropriate
intervention (Choice B). Notifying the healthcare provider is an appropriate intervention (Choice C).
Choice A is incorrect. The nurse has observed a late deceleration. Late decelerations or dips in the
fetal heart rate that occur after a contraction are a non-reassuring sign on a fetal heart rate strip.
Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left
side, not supine quickly. If the nurse were to lay the mother supine, she could further aggravate the
uteroplacental insufficiency that is likely contributing to the late deceleration. She needs to increase
blood flow to the placenta, therefore positioning the mother on her left side is the correct nursing
intervention to do this.
Choice D is incorrect. Although the nurse has noted a non-reassuring fetal heart rate, it is
unnecessary to prepare for delivery at this time. There are interventions that the nurse and the
healthcare team can take to address the fetus's heart rate before needing to do an emergency
delivery.
NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction;
Problems with Labor and Delivery
The nurse is helping a 7-year-old post-abdominal surgery patient who is attempting to make a
pinwheel spin by blowing on it. The child, however, is unable to make it spin. What would be the
most appropriate action by the nurse?
A. Praise the child for his/her attempts.
[36%]
B. Call the respiratory therapist and have the child start incentive spirometry.
[21%]
C. Instruct the child to turn from side to side.
[9%]
D. Show the child how to make the pinwheel spin.
[33%] - verified answer Explanation
The emergency department (ED) nurse is caring for a client with acetaminophen toxicity. The nurse
anticipates a prescription for which medication?
A. Acetylcysteine
[85%]
B. Deferoxamine mesylate
[5%]
C. Succimer
[2%]
D. Flumazenil
[7%] - verified answer Explanation
Choice A is correct. Acetylcysteine is given to convert toxic metabolites to nontoxic ones.
Acetaminophen is one of the most commonly used oral analgesics and antipyretics. The maximum
dose for an adult is four grams in a 24-hour period. Toxicity starts after the consumption of seven
grams.
Choices B, C, and D are incorrect. Deferoxamine mesylate is the antidote for iron intoxication.
Succimer is the antidote for lead poisoning. Flumazenil is the antidote for the sedative effect of
benzodiazepines.
Additional Info
Acute hepatic necrosis may result from large ingestion of acetaminophen. Acute hepatotoxicity can
usually be reversed with acetylcysteine, whereas long-term toxicity is more likely to be permanent.
The issue with acetaminophen toxicity is that most cases come from accidental ingestion because
clients are unaware the cold remedies contain acetaminophen. Thus, appropriate education must be
provided to avoid this type of toxicity.
The nurse is caring for several clients in a long-term care facility. Which interventions should the
nurse implement to reduce the risk of injury for these clients? Select all that apply.
A. Avoid administering ibuprofen at night.
[3%]
,B. Secure the call button to the side of the bed.
[32%]
C. Keep the bed in the lowest position.
[38%]
D. Complete a fall risk assessment within 24 hours of admission.
[27%] - verified answer Explanation
Choices B and C are correct. Falls and injuries can be reduced by ensuring the call button are
accessible (Choice B) and within easy reach for the client. The call light can be clipped or secured
when the client is in bed to prevent falling out of reach.
Most clients in long-term facilities need some assistance and are at risk of falls. The nurse must
complete a fall risk assessment at admission or within 2 hours of admission. Setting the bed to the
lowest position (Choice C) would reduce the risk of injury in the event of a fall because such
positioning keeps the patient at a closer distance to the floor.
Choices A and D are incorrect. Evening administration of NSAIDS do not increase the risk of falls. On
the other hand, the nurse should avoid administering diuretics and laxatives before the patient's
sleep to reduce urgent bathroom needs. Having to push for urgent bathroom needs may lead to
falls. The nurse should complete a fall risk assessment upon admission or within 2 hours of
admission to promptly implement fall-prevention interventions for high-risk clients. Waiting 24
hours to complete a fall-risk assessment is inappropriate because a preventable fall may have
already happened.
Additional Info
Universal fall precautions involve
• Monitor the client's activities and behavior as often as possible, preferably every 30 to 60 minutes.
• Teach the client and family about the fall prevention program to become safety partners.
• Remind the client to call for help before getting out of bed or a chair.
• Help the client get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs
before transferring client's.
• Teach clients to use the grab bars when walking in the hall without assistive devices or when using
the bathroom.
• Provide or remind the client to use a walker or cane for
A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an
expected finding due to immobility?
,A. A decrease in bone density
[2%]
B. Loss of short-term memory
[66%]
C. Atelectasis
[10%]
D. High serum calcium level
[21%] - verified answer Explanation
Choice B is correct. Loss of short-term memory is not an expected complication of prolonged
immobility and warrants further assessment. Short-term memory loss may indicate medication
effects, Alzheimer's dementia, or Lewy body dementia, etc.
Choices A, C, and D are incorrect. Decreased bone density (osteoporosis), atelectasis, and
hypercalcemia are all expected due to prolonged immobility.
Risk factors related to mobility can affect every organ system. The musculoskeletal system can
experience contractures, joint ankylosis, and depletion of necessary minerals/loss of bone density.
Hypercalcemia (Choice D) may occur with prolonged immobility. Prolonged immobilization deranges
bone remodeling because of the lack of mechanical stress. This causes an imbalance between bone
formation and bone resorption where resorption exceeds formation. Consequently, there is a net
efflux of calcium from the bone. Respiratory complications such as atelectasis (Choice C) and
pneumonia may occur. Gastrointestinal manifestations (constipation) may occur due to decreased
peristalsis. Immobile individuals are also more prone to orthostatic hypotension, decreased
metabolism, and skin breakdown/decubitus ulceration.
The nurse is assessing a patient in active labor. Her contractions are increasing in frequency as well
as the duration and presenting 5 minutes apart for 60 seconds each with every contraction. The fetal
heart rate begins to slow from 150 to 110 after the decrease starts. Which of the following are
priority nursing actions for this situation?
Select all that apply.
A. Reposition the mother to a supine position
[7%]
B. Administer 100% FiO2 via face mask
[34%]
, C. Notify the healthcare provider
[37%]
D. Prepare for delivery
[21%] - verified answer Explanation
Choices B and C are correct. Late decelerations or dips in the fetal heart rate that occur after a
contraction are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this
sign, she will need to intervene quickly. Administering 100% FiO2 via a face mask is an appropriate
intervention (Choice B). Notifying the healthcare provider is an appropriate intervention (Choice C).
Choice A is incorrect. The nurse has observed a late deceleration. Late decelerations or dips in the
fetal heart rate that occur after a contraction are a non-reassuring sign on a fetal heart rate strip.
Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left
side, not supine quickly. If the nurse were to lay the mother supine, she could further aggravate the
uteroplacental insufficiency that is likely contributing to the late deceleration. She needs to increase
blood flow to the placenta, therefore positioning the mother on her left side is the correct nursing
intervention to do this.
Choice D is incorrect. Although the nurse has noted a non-reassuring fetal heart rate, it is
unnecessary to prepare for delivery at this time. There are interventions that the nurse and the
healthcare team can take to address the fetus's heart rate before needing to do an emergency
delivery.
NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Risk of the potential reduction;
Problems with Labor and Delivery
The nurse is helping a 7-year-old post-abdominal surgery patient who is attempting to make a
pinwheel spin by blowing on it. The child, however, is unable to make it spin. What would be the
most appropriate action by the nurse?
A. Praise the child for his/her attempts.
[36%]
B. Call the respiratory therapist and have the child start incentive spirometry.
[21%]
C. Instruct the child to turn from side to side.
[9%]
D. Show the child how to make the pinwheel spin.
[33%] - verified answer Explanation
