A client on a morphine PCA pump is noted to be drowsy and lethargic with pinpoint pupils and the following vitals: pulse 84 beats/minute, respiratory rate 10 breaths/minute, blood pressure 90/50 mm Hg. What is the nurse's best action?
Discuss possible opiate dependence with the client's provider.
Note the effectiveness of the analgesia in the client's chart.
Encourage the client to turn over, and cough and take deep breaths.
Prepare to administer naloxone and provide respiratory support.
The Correct Answer is D
a) While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.
b) Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.
c) Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.
d) The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) Taking furosemide at 0800 is often recommended to promote diuresis during the day, allowing the client to manage fluid balance while awake and minimizing the need for frequent urination during the night.
b) Taking furosemide at 1900 may contribute to nocturnal diuresis, potentially affecting sleep.
c) Taking furosemide at 2200 is not ideal as it may lead to increased nighttime urination.
d) Taking furosemide at 1600 may not provide the optimal timing to balance diuretic effects throughout the day.
Correct Answer is B
Explanation
A) Taking ibuprofen with meals is a good practice to reduce the risk of stomach upset.
B) Tinnitus is not a typical side effect of ibuprofen, and this statement may indicate a misunderstanding or confusion with another medication.
C) Stopping alcohol consumption is advisable as it can increase the risk of gastrointestinal bleeding when combined with ibuprofen.
D) The dosing information provided is within the typical recommended range for ibuprofen, and the statement is accurate.
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