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 A
Explanation
A. The benefit to eating frequent small meals during the day: Nonselective beta-blockers can mask symptoms of hypoglycemia, making it harder for patients with diabetes to recognize low
blood sugar levels. Eating frequent small meals can help stabilize blood sugar levels and reduce the risk of hypoglycemia.
B. Perform more frequent blood glucose checks due to effects of the drug: While it's important for patients with diabetes to monitor their blood glucose levels regularly, this instruction doesn't directly address the potential masking of hypoglycemia symptoms by beta-blockers.
C. The need to weight himself once per week at the same time of the day: Weight monitoring is important for overall health management but is not specifically related to the use of nonselective beta-blockers in diabetes management.
D. The correct method for taking their own apical pulse: Knowing how to take one's own apical pulse is important for some individuals, but it's not directly related to the management of
diabetes with nonselective beta-blockers.
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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