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NurseDive Free Nursing Practice Question
A client on a morphine PCA pump is noted to be drowsy and lethargic with pinpoint pupils and the following vitals: pulse 84 beats/minute, respiratory rate 10 breaths/minute, blood pressure 90/50 mm Hg. What is the nurse's best action?
A. Discuss possible opiate dependence with the client's provider.
While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.
B. Note the effectiveness of the analgesia in the client's chart.
Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.
C. Encourage the client to turn over, and cough and take deep breaths.
Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.
D. Prepare to administer naloxone and provide respiratory support.
The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.
This question is an excerpt from Nurse Dive's nursing test bank - Ramsussen Section 4 Module 11. Pharmocology For Professional Nursing Proctored Exam. Take the full exam now
Full Explanation
a) While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.
b) Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.
c) Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.
d) The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.
Similar Questions
In which situation would the nurse hold digoxin?
A. When the lab reports a digoxin level 1.2 ng/mL
A digoxin level of 1.2 ng/mL is within the therapeutic range, and holding the medication based solely on the level may not be necessary.
B. When the client complains of seeing yellow-green halos
Seeing yellow-green halos is a symptom of digoxin toxicity, and holding the medication is appropriate to prevent further adverse effects.
C. When the client is edematous
Edema alone may not be a contraindication for administering digoxin; the nurse would assess other factors such as heart rate and rhythm.
D. When the client is pacing and very thirsty
Pacing and thirst are not specific signs of digoxin toxicity, and the nurse would need to assess other symptoms and factors before deciding to hold the medication.
Full Explanation
a) A digoxin level of 1.2 ng/mL is within the therapeutic range, and holding the medication based solely on the level may not be necessary.
b) Seeing yellow-green halos is a symptom of digoxin toxicity, and holding the medication is appropriate to prevent further adverse effects.
c) Edema alone may not be a contraindication for administering digoxin; the nurse would assess other factors such as heart rate and rhythm.
d) Pacing and thirst are not specific signs of digoxin toxicity, and the nurse would need to assess other symptoms and factors before deciding to hold the medication.
Which of these statements best describes the concept of half-life?
A. It is the time it takes for half of the drug in the body to reach the receptors.
This statement inaccurately describes the concept of half-life. Half-life refers to the time it takes for the drug concentration in the body to decrease by half, not the time it takes for the drug to reach receptors.
B. It is the time it takes for the amount of drug in the body to be decreased by half. C) It is time it takes for half of the drug in the body to be distributed.
C. It is the time it takes for the shelf-life of the drug to be decreased by half.
This statement inaccurately describes the concept of half-life. Half-life is not related to the distribution of the drug in the body.
Full Explanation
a) This statement inaccurately describes the concept of half-life. Half-life refers to the time it takes for the drug concentration in the body to decrease by half, not the time it takes for the drug to reach receptors.
c) This statement inaccurately describes the concept of half-life. Half-life is not related to the distribution of the drug in the body.
d) This statement inaccurately describes the concept of half-life. Half-life is not related to the shelf-life of the drug.
The nurse is doing discharge teaching with the parent of an asthmatic child who will be going home on steroids. Which of these comments by the parent would indicate an accurate understanding of discharge teaching regarding these medications?
A. My child may need to take a gastric acid suppressor while taking steroids.
The need for a gastric acid suppressor is not a common consideration when taking steroids.
B. Prolonged steroid use may lead to addiction.
Prolonged steroid use does not typically lead to addiction.
C. Prolonged steroid use causes children to grow prematurely tall because they enhance growth.
Prolonged steroid use, particularly in children, may lead to enhanced growth and potentially premature tall stature.
D. Steroids cause weight loss and dehydration in children because they cause type 1 diabetes.
Steroids may cause weight gain rather than weight loss, and they do not typically cause type 1 diabetes.
Full Explanation
a) The need for a gastric acid suppressor is not a common consideration when taking steroids.
b) Prolonged steroid use does not typically lead to addiction.
c) Prolonged steroid use, particularly in children, may lead to enhanced growth and potentially premature tall stature.
d) Steroids may cause weight gain rather than weight loss, and they do not typically cause type 1 diabetes.