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. Dobutamine is a sympathomimetic drug used to increase cardiac output in conditions such as heart failure. It is not an antidote for cholinergic drug overdose.
B. Atropine sulfate is the antidote for cholinergic drug overdose. It acts as a competitive antagonist to acetylcholine at muscarinic receptors, counteracting the effects of excessive cholinergic stimulation.
C. Atenolol is a beta-blocker used to manage hypertension and certain cardiac conditions. It is not an antidote for cholinergic drug overdose.
D. Bethanechol is a cholinergic agonist used to stimulate bladder contractions in urinary retention. It is not an antidote for cholinergic drug overdose; in fact, it would exacerbate cholinergic effects.
Correct Answer is B
Explanation
A. Myoclonic seizures are characterized by sudden, brief muscle jerks or twitches. These
movements are usually more pronounced and may involve multiple muscle groups compared to the described behavior, which involves a brief pause in activity without muscle jerks.
B. Absence seizures are characterized by brief episodes of staring or blanking out, often lasting for a few seconds. During an absence seizure, the child may appear to be staring into space, unaware of their surroundings. After the seizure, the child typically resumes their previous
activity without any memory of the event.
C. Status epilepticus refers to a prolonged seizure or a series of seizures without full recovery of consciousness between seizures. This condition is a medical emergency and presents with continuous or recurrent seizures without regaining consciousness.
D. Tonic-clonic seizures involve a sequence of tonic (stiffening) and clonic (jerking) phases, often accompanied by loss of consciousness and sometimes preceded by an aura. The described behavior does not fit the pattern of a tonic-clonic seizure, which typically involves more noticeable motor activity and loss of consciousness.
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