A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.
The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?

Decreased temperature.

Polyuria.

Bradycardia.

Increased respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Decreased temperature is not a typical sign of naloxone reversing the effects of an opioid overdose. Opioid overdose commonly leads to respiratory depression and hypoxia, but it does not significantly affect body temperature. Naloxone works by binding to the same receptors in the brain that opioids bind to, thereby reversing the effects of the overdose. The primary signs of successful reversal include improved respiratory rate and increased alertness, not changes in body temperature.

Choice B rationale:

Polyuria (excessive urination) is not a specific indicator of naloxone effectiveness. Opioid overdose and naloxone administration primarily affect the central nervous system and respiratory function, not urinary output. Naloxone's effects are more evident in the client's level of consciousness, respiratory rate, and overall responsiveness.

Choice C rationale:

Bradycardia (slow heart rate) is not an expected indicator of naloxone effectiveness. Opioid overdose typically causes respiratory depression, leading to a decreased respiratory rate and oxygen saturation. Naloxone works by reversing this respiratory depression and improving ventilation. Consequently, increased respiratory rate, not heart rate, is a more relevant indicator of naloxone's effectiveness in reversing opioid overdose.

Choice D rationale:

This is the correct answer. Increased respiratory rate is a key indicator that naloxone is reversing the effects of an opioid overdose. Opioid overdose depresses the respiratory system, leading to slow and shallow breathing. Naloxone, as an opioid receptor antagonist, rapidly reverses this effect, leading to a noticeable increase in the client's respiratory rate. Monitoring for improved breathing and increased oxygen saturation is crucial to assessing the effectiveness of naloxone in treating opioid overdose.

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Correct Answer is C

Explanation

Choice A rationale:

Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.

Choice B rationale:

Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.

Choice C rationale:

Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.

Choice D rationale:

Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.

A. "Participate in range-of-motion exercises." B. "Place a pillow under your knees while in bed." C. "Remain on bed rest for 24 hours following the procedure." D. "Use an incentive spirometer every 4 hours."

Correct Answer is A

Explanation

A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.

B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.

C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).

D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.

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A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.
The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?