A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Expresses that they cannot get enough air to breathe.

Respiratory rate of 7 breaths/minute.

Bilateral wheezing on auscultation.

Pulse oximeter reading of 89% on room air.

Answer and Explanation

The Correct Answer is B

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

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Correct Answer is ["31"]

Explanation

To find out how many gtt/min the nurse should regulate the infusion;

We can use the following formula:

Flowrate(gtt/min) = Totalvolume(mL) / Time(min) × Dropfactor(gtt/mL)

Given:

Total volume = 500 mL

Time = 4 hours = 240 minutes (since 1 hour = 60 minutes)

Drop factor = 15 gtt/mL

Substituting the given values into the formula:

Flowrate(gtt/min) =500mL/240min ×15gtt/mL

After performing the calculation, we find that the flow rate equals 31.25 gtt/min.

So, the nurse should regulate the infusion to 31 gtt/min (rounded to the nearest whole number).

A. Monitor blood pressure. B. Assess urine output. C. Obtain daily weights. D. Perform a bladder scan.

Correct Answer is A

Explanation

A) Monitor blood pressure:
This is the correct answer. Tamsulosin, like other alpha-blockers, can cause orthostatic hypotension, which is characterized by a sudden drop in blood pressure when transitioning from lying down or sitting to standing. Monitoring blood pressure, particularly when initiating therapy or adjusting the dosage, helps detect and manage hypotensive episodes. Clients should be advised to change positions slowly to minimize the risk of falls or injury.

B) Assess urine output:
While tamsulosin can affect urinary function by relaxing smooth muscle in the prostate and bladder neck, it typically does not significantly impact urine output. Therefore, monitoring urine output is not a primary intervention for assessing adverse reactions to tamsulosin.

C) Obtain daily weights:
Tamsulosin is not typically associated with significant fluid retention or changes in body weight. Daily weight measurements are more relevant for assessing fluid balance in clients receiving medications such as diuretics or those with conditions like heart failure or renal disease.

D) Perform a bladder scan:
Tamsulosin does not directly affect bladder volume or urinary retention to the extent that necessitates routine bladder scanning. Bladder scans are typically performed in clients with suspected urinary retention or those at risk for urinary retention due to conditions like BPH, but it's not a standard intervention for monitoring adverse reactions to tamsulosin.

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A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for dextrose 5% in water 500 mL IV to be infused over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

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Correct Answer is A

Explanation

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