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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The drug level is at a toxic level, and the dosage needs to be reduced. Phenytoin has a narrow therapeutic range, and levels above 20 mcg/mL are considered to be in the toxic range.
Symptoms of phenytoin toxicity can include nystagmus, ataxia, slurred speech, and confusion. Therefore, if a patient's phenytoin level is 23 mcg/mL, the nurse should be concerned about potential toxicity and consult with the healthcare provider to adjust the dosage.
B. The patient's seizures should be under control if she is also taking a second antiepileptic drug.

While combination therapy with multiple antiepileptic drugs can help control seizures, a phenytoin level of 23 mcg/mL is still concerning for toxicity and requires intervention.
C. The patient is at risk for seizures because the drug level is not at a therapeutic level. A phenytoin level of 23 mcg/mL is actually above the therapeutic range and is more indicative of toxicity rather than subtherapeutic levels.

D. The patient's seizures should be under control because this is a therapeutic drug level. A phenytoin level of 23 mcg/mL is not within the therapeutic range but rather in the toxic range, so the patient may experience symptoms of toxicity rather than having adequate seizure control.

A. CT of the brain B. Electroencephalogram C. Brain stem reflexes D. Pupil response

Correct Answer is C

Explanation

A. CT of the brain can proceed regardless of atropine administration, as it does not directly affect the assessment of brain stem reflexes.
B. Electroencephalogram (EEG) can also proceed regardless of atropine administration, as it evaluates brain electrical activity rather than brain stem reflexes.
C. Assessment of brain stem reflexes should be postponed until all atropine is excreted and no

longer exerting its effects. Atropine can mask or alter the pupillary response and other brain stem reflexes, such as gag reflex and cough reflex, which are important indicators of neurological function.
D. Pupil response assessment should be postponed until atropine effects have dissipated, as

atropine can cause pupillary dilation, which may interfere with accurate assessment of pupil size and reactivity

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a routine appointment, a patient with a history of seizures is found to have a phenytoin level of 23 mcg/mL. What concern will the nurse have, if any?

Correct Answer is A

Explanation

While being intubated, a client with a head injury experienced bradycardia. Atropine was consequently administered. What assessment should be postponed until all atropine is excreted and no longer exerting an effect?

Correct Answer is C

Explanation

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen. Which patient should not receive acetaminophen?

A nurse is teaching a patient who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the patient to minimize anticholinergic effects?

The nurse is caring for a 64-year-old male client with diabetes who is being treated with a nonselective beta-blocker. What health education should the nurse prioritize with this client?

A patient has been taking phenobarbital for 2 weeks as part of his therapy for epilepsy. He tells the nurse that he feels tense and that the least little thing bothers him now. Which is the correct explanation for this problem?

The barbiturate phenobarbital is prescribed for a patient with epilepsy. While assessing the patient's current medications, the nurse recognizes that interactions may occur with which drugs? (Select all that apply.)

The nurse is reviewing the use of central nervous system stimulants. Which of these are indications for this class of drugs? (Select all that apply.)

The nurse has given medication instructions to a patient receiving phenytoin. Which statement by the patient indicates that the patient has an adequate understanding of the instructions?