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 B
Explanation
A. Acetaminophen is generally considered safe for patients with a history of peptic ulcer disease.
It does not irritate the gastrointestinal mucosa like nonsteroidal anti-inflammatory drugs (NSAIDs).
B. Patients with a history of liver disease should not receive acetaminophen or should use it with caution and under close supervision, as acetaminophen is metabolized in the liver. Liver
impairment can lead to decreased metabolism of acetaminophen, potentially resulting in drug accumulation and hepatotoxicity.
C. Acetaminophen is commonly used to relieve mild to moderate headaches. However, the appropriateness of acetaminophen use in this scenario depends on the patient's overall health status and any contraindications specific to the individual.
D. Acetaminophen is often used to reduce fever. A fever of 101°F (38.3°C) alone does not necessarily contraindicate acetaminophen use, but caution should be exercised in patients with liver disease.
Correct Answer is B
Explanation
A. Signs of bone marrow depression are not typically associated with antiepileptic drugs. This adverse effect is more commonly seen with medications such as chemotherapy agents.
B. Increased risk of suicidal thoughts and behaviors is a well-documented concern with antiepileptic drugs, particularly when used for psychiatric indications or in certain patient populations. The FDA has issued warnings regarding this risk, and healthcare providers should monitor patients for changes in mood, behavior, and suicidal ideation.
C. While some antiepileptic drugs may have cardiovascular effects, such as prolongation of the QT interval, the FDA warning specifically highlights the risk of suicidal thoughts and behaviors rather than cardiovascular events like strokes.
D. Indications of drug addiction and dependency are not typically associated with antiepileptic drugs. These medications are not central nervous system depressants and do not produce the euphoria or withdrawal symptoms characteristic of addictive substances.
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