A nurse is assessing a client who has a history of substance abuse.

Which of the following findings should the nurse report to the provider immediately?

Dilated pupils

Slurred speech

Agitation and restlessness

Respiratory depression

Answer and Explanation

The Correct Answer is D

Respiratory depression

Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.

Incorrect options:

A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.

B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.

C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.

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Correct Answer is D

Explanation

"I think that I can drive myself home after the procedure."

Rationale: The client should be informed that they cannot drive themselves home after the procedure, as they will be under the influence of sedation and may experience drowsiness, impaired judgment, and delayed reaction time. The client should arrange for a responsible adult to accompany them home and stay with them until the effects of sedation wear off.

Incorrect options:

A) "I understand that I will be sedated during the procedure." - This is a correct statement, as sedation is usually administered during a colonoscopy to reduce discomfort and anxiety.

B) "I know that I have to drink a lot of clear liquids before the procedure." - This is a correct statement, as drinking clear liquids before the procedure helps to cleanse the bowel and improve visualization.

C) "I expect that I will have some abdominal cramps and gas after the procedure." - This is a correct statement, as abdominal cramps and gas are common after a colonoscopy due to air insufflation during the procedure. The client should be advised to ambulate and pass gas as tolerated to relieve these symptoms.

A. Apply suction for no longer than 10 seconds at a time. B. Preoxygenate the client with 100% oxygen before suctioning. C. Limit the number of suction passes to three per session. D. All of the above

Correct Answer is D

Explanation

All of the above

Rationale: The nurse should apply suction for no longer than 10 seconds at a time, preoxygenate the client with 100% oxygen before suctioning, and limit the number of suction passes to three per session to prevent hypoxia during tracheostomy suctioning. These actions help to minimize the interruption of oxygen delivery and reduce the risk of mucosal trauma and bleeding.

Incorrect options:

None

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A nurse is assessing a client who has a history of substance abuse. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining informed consent from a client who is scheduled for a colonoscopy. Which of the following statements by the client indicates a need for further clarification?

Correct Answer is D

Explanation

A nurse is caring for a client who has a tracheostomy tube and requires suctioning. Which of the following actions should the nurse take to prevent hypoxia during the procedure?

Correct Answer is D

Explanation

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A nurse is assessing a client who has a history of substance abuse.

Which of the following findings should the nurse report to the provider immediately?