A nurse is assessing a client who has opioid toxicity. Which of the following findings should the nurse expect?
Heart rate 112/min
Blood pressure 168/90 mm Hg
Respiratory rate 10/min
Temperature 38.2°C (100.8°F)
The Correct Answer is C
Opioid toxicity can cause difficulties with breathing and an opioid overdose can lead to death1. A respiratory rate of 10/min is considered low and could be a sign of opioid toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When someone is having a seizure, it is important to protect their head from injury. One way to do this is by placing something soft and flat, like a folded jacket or towel, under their head1. It is also important to stay with the person until the seizure ends and they are fully awake, and to help them sit in a safe place after it ends1
Correct Answer is C
Explanation
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
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