A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?

Naloxone

Protamine sulfate

Acetylcysteine

Flumazenil

Answer and Explanation

The Correct Answer is A

A. Naloxone is a medication used as an opioid antagonist to reverse the effects of opioid overdose, including respiratory depression and hypotension. In this scenario, the client's symptoms suggest opioid-induced respiratory depression, making naloxone the appropriate choice to reverse the effects of morphine.
B. Protamine sulfate is used to reverse the anticoagulant effects of heparin, not for treating opioid-induced respiratory depression and hypotension.
C. Acetylcysteine is used as an antidote for acetaminophen (paracetamol) overdose, not for treating opioid-induced respiratory depression and hypotension.
D. Flumazenil is a medication used as a benzodiazepine antagonist to reverse the effects of benzodiazepine overdose or sedation.

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Correct Answer is ["A","C","D","E","G"]

Explanation

Improvement in blood pressure would suggest better cardiovascular stability

A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.

An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.

A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.

A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.

Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.

A. Turn the client on their side. B. Perform a neurologic check. C. Obtain the client's vital signs. D. Notify the rapid response team.

Correct Answer is A

Explanation

A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.

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A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E","G"]

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