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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

a) St. John's Wort is known to increase the risk of bleeding, particularly when used in conjunction with anticoagulant medications. This effect is of concern and may require adjustments in the treatment plan.

b) While St. John's Wort can interact with various drugs, increasing the risk of bleeding is a more immediate concern.

c) St. John's Wort does not counteract the effects of CNS depressants; it may actually enhance the effects of these drugs.

d) St. John's Wort is known to induce the metabolism of some drugs, potentially reducing their effectiveness, but the immediate concern is the risk of bleeding.

A. Decreased bone density B. Ovarian cancer C. Stroke D. Increased colon cancer E. Deep vein thrombosis

Correct Answer is ["B","C","E"]

Explanation

A) This is not a risk of estrogen/progestin therapy. In fact, estrogen/progestin therapy can help prevent osteoporosis and fractures by increasing bone density and strength.

B) This is a possible risk of estrogen/progestin therapy. Some studies have suggested that taking estrogen/progestin therapy for more than five years may increase the risk of ovarian cancer. However, other studies have not found this association

C) This is a serious risk of estrogen/progestin therapy. Estrogen/progestin therapy can increase the risk of blood clots, which can lead to stroke or heart attack. The risk is higher for women who smoke, have high blood pressure, diabetes, or a history of cardiovascular disease.

D) This is not a risk of estrogen/progestin therapy. In fact, some studies have suggested that estrogen/progestin therapy may reduce the risk of colon cancer by lowering inflammation and promoting regular bowel movements.

E) This is another serious risk of estrogen/progestin therapy. Deep vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the leg. It can cause pain, swelling, and redness in the affected area. If the clot breaks off and travels to the lungs, it can cause a life threatening condition called pulmonary embolism (PE). Estrogen/progestin therapy can increase the risk of DVT and PE by making the blood more likely to clot

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a history from a client who discloses daily use of St. John's Wort in addition to prescription drugs. Which effect of this dietary supplement would most concern the nurse?

Correct Answer is A

Explanation

The nurse is providing client education for a postmenopausal client; which risks associated with estrogen/progestin therapy should the nurse discuss with the client? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is preparing discharge teaching for a client who will be going home on warfarin. Which of these client statements indicates the need for further instruction?

A client has had emergency surgery for a ruptured appendix. Before surgery, the client was taking dexamethasone for three years. With the client's steroid use history, for which complication will the nurse monitor in the recovery phase?

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The nurse is caring for four different clients. Which of these clients should the nurse assess first?

The diabetic client is scheduled for a computed tomography (CT) scan with intravenous contrast. What education will the nurse provide? (Select all that apply.)

A client with type 1 diabetes who takes insulin reports taking propranolol for hypertension. Why is the nurse concerned?

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