A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 breaths/minute. The nurse prepares for which priority action at this time?
Assessment of the patient's pain level
Close observation of signs of opioid tolerance
Immediate intubation and artificial ventilation
Administration of naloxone
The Correct Answer is D
A. Assessment of the patient's pain level: While pain assessment is important, the patient's lethargy and shallow respirations indicate a potential opioid overdose, which takes priority.
B. Close observation of signs of opioid tolerance: The patient's symptoms are indicative of opioid overdose, not tolerance.
C. Immediate intubation and artificial ventilation: While respiratory support may eventually be necessary if the patient's condition deteriorates further, administering naloxone to reverse the opioid effects is the initial priority.
D. Administration of naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors, which can rapidly restore normal respiratory function and
consciousness in patients experiencing opioid-induced respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tachycardia is not typically associated with cholinergic drug effects. Cholinergic stimulation tends to slow down the heart rate rather than increase it.
B. Palpitations may occur with certain cardiac arrhythmias or in response to sympathetic stimulation, but they are not typically associated with cholinergic drug effects.
C. Cholinergic drugs are more likely to cause vasodilation rather than vasoconstriction.
Therefore, vasoconstriction is not a common cardiovascular effect of cholinergic drug therapy.
D. Bradycardia is a common cardiovascular effect of cholinergic drug therapy. Cholinergic stimulation slows down the heart rate by increasing parasympathetic activity, particularly at the
sinoatrial (SA) node. Therefore, bradycardia is the cardiovascular effect that nurses should monitor for when administering cholinergic drugs.
Correct Answer is B
Explanation
A. Diarrhea is not typically associated with ergotamine toxicity. Gastrointestinal symptoms such as nausea and vomiting are more common adverse effects of ergotamine use.
B. Delirium is a potential sign of ergotamine toxicity. At toxic levels, ergotamine can cause central nervous system symptoms such as confusion, hallucinations, and delirium.
C. Hypotension may occur as an adverse effect of ergotamine due to its vasoconstrictive properties. However, hypotension alone may not indicate ergotamine toxicity.
D. Bradycardia is not a typical adverse effect of ergotamine. Ergotamine is more commonly associated with vasoconstriction and can lead to hypertension or tachycardia rather than bradycardia.
A. Diarrhea is not typically associated with ergotamine toxicity. Gastrointestinal symptoms such as nausea and vomiting are more common adverse effects of ergotamine use.
B. Delirium is a potential sign of ergotamine toxicity. At toxic levels, ergotamine can cause central nervous system symptoms such as confusion, hallucinations, and delirium.
C. Hypotension may occur as an adverse effect of ergotamine due to its vasoconstrictive properties. However, hypotension alone may not indicate ergotamine toxicity.
D. Bradycardia is not a typical adverse effect of ergotamine. Ergotamine is more commonly associated with vasoconstriction and can lead to hypertension or tachycardia rather than bradycardia.
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