Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client that was overdosed with fentanyl. The nurse is concerned that the client is experiencing opioid toxicity triad. Which of the following signs indicate that the client is experiencing opioid toxicity triad? (Select All That Apply.).
A. Coma
Coma is a common symptom of opioid toxicity, including toxicity from fentanyl.
B. Respiratory depression
Respiratory depression is a hallmark of opioid toxicity and can be life-threatening.
C. Dilated pupils
Dilated pupils are generally associated with stimulant overdose, not opioid toxicity. Opioid toxicity typically causes pinpoint pupils.
D. Pinpoint pupils
Pinpoint pupils (miosis) are a classic sign of opioid toxicity and are present in the opioid toxicity triad.
This question is an excerpt from Nurse Dive's nursing test bank - Ati nurs 180 pharmacology proctored exam. Take the full exam now
Full Explanation
A. Coma is a common symptom of opioid toxicity, including toxicity from fentanyl.
B. Respiratory depression is a hallmark of opioid toxicity and can be life-threatening.
C. Dilated pupils are generally associated with stimulant overdose, not opioid toxicity. Opioid toxicity typically causes pinpoint pupils.
D. Pinpoint pupils (miosis) are a classic sign of opioid toxicity and are present in the opioid toxicity triad.
Similar Questions
A nurse is caring for a client who has overdosed on morphine sulfate (Astramorph) and was provided naloxone (Narcan) via subcutaneous route 15 minutes ago. Which of the following signs indicate that the client has abstinence syndrome? (Select All That Apply.).
A. Coma
Coma is typically a symptom of opioid overdose, not abstinence syndrome.
B. Pinpoint pupils
Pinpoint pupils are commonly associated with opioid toxicity, not abstinence syndrome.
C. Fever
Fever is a sign of abstinence syndrome, which can occur after opioid withdrawal.
D. Vomiting
Vomiting is also a symptom of abstinence syndrome, which is a withdrawal reaction that can occur when naloxone reverses opioid effects.
Full Explanation
A. Coma is typically a symptom of opioid overdose, not abstinence syndrome.
B. Pinpoint pupils are commonly associated with opioid toxicity, not abstinence syndrome.
C. Fever is a sign of abstinence syndrome, which can occur after opioid withdrawal.
D. Vomiting is also a symptom of abstinence syndrome, which is a withdrawal reaction that can occur when naloxone reverses opioid effects.
A nurse is caring for a client with a prescription for celecoxib (Celebrex). The nurse tells the client to report which of the following adverse drug reactions?
A. Diarrhea
Diarrhea is a known side effect of celecoxib but not typically a sign of a serious reaction.
B. Headache
Headache is a mild side effect that may occur with celecoxib use but is not a severe adverse reaction.
C. Nausea
Nausea is a common side effect of many medications, including celecoxib, but is not a critical issue unless severe.
D. Chest pressure
Chest pressure could indicate cardiovascular problems, which is a serious adverse effect of celecoxib and other COX-2 inhibitors. Clients should report this immediately, as it may indicate a risk for myocardial infarction or stroke.
Full Explanation
A. Diarrhea is a known side effect of celecoxib but not typically a sign of a serious reaction.
B. Headache is a mild side effect that may occur with celecoxib use but is not a severe adverse reaction.
C. Nausea is a common side effect of many medications, including celecoxib, but is not a critical issue unless severe.
D. Chest pressure could indicate cardiovascular problems, which is a serious adverse effect of celecoxib and other COX-2 inhibitors. Clients should report this immediately, as it may indicate a risk for myocardial infarction or stroke.
A nurse is caring for a client who is taking acetaminophen (Tylenol) at regular intervals for mild pain. The nurse should tell the client to report which of the following early manifestations of acetaminophen toxicity?
A. Petechiae
Petechiae is an early sign of acetaminophen toxicity. It indicates a potential bleeding disorder due to liver damage, which can occur from prolonged or high-dose use of acetaminophen.
B. Osteoporosis
Osteoporosis is not a symptom of acetaminophen toxicity.
C. Pneumonia
Pneumonia is unrelated to acetaminophen toxicity and is more likely to occur due to infections.
D. Diaphoresis
Diaphoresis (sweating) is not a primary early symptom of acetaminophen toxicity, although it could occur in later stages of liver failure.
Full Explanation
A. Petechiae is an early sign of acetaminophen toxicity. It indicates a potential bleeding disorder due to liver damage, which can occur from prolonged or high-dose use of acetaminophen.
B. Osteoporosis is not a symptom of acetaminophen toxicity.
C. Pneumonia is unrelated to acetaminophen toxicity and is more likely to occur due to infections.
D. Diaphoresis (sweating) is not a primary early symptom of acetaminophen toxicity, although it could occur in later stages of liver failure.