A nurse is assisting in the admission of a client who had recently given birth and is presenting to the emergency department with acute opioid toxicity. Which of the following findings should the nurse expect?

Hypothermia.

Hypertension.

Diaphoresis.

Mydriasis.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.

Choice B reason:

Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.

Choice C reason:

Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.

Choice D reason:

Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.

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Correct Answer is B

Explanation

Choice A reason:

Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.

Choice B reason:

Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.

Choice C reason:

Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.

Choice D reason:

Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.

A. Rotavirus. B. Hepatitis B (Hep B). C. Varicella. D. Haemophilus influenza (Hib).

Correct Answer is C

Explanation

Choice A reason:

Rotavirus The nurse does not need to administer the Rotavirus vaccine in this scenario. Rotavirus immunization is typically given to infants between 2 and 6 months of age to protect against severe diarrhea caused by the virus. Since the child in question is 4 years old and up to date on current immunizations, this vaccine is not necessary.

Choice B reason:

Hepatitis B (Hep B) Similarly, the Hepatitis B vaccine is usually given shortly after birth and completed in a series of doses over the first year of life. Since the 4-year-old child is up to date on immunizations, the Hep B vaccine would have already been administered as part of the routine childhood vaccination schedule.

Choice C reason:

Varicella The Varicella vaccine, also known as the chickenpox vaccine, is typically given between 12 and 15 months of age and then again at 4 to 6 years old. Since the child is 4 years old and up to date on immunizations, it is now time for them to receive the second dose of the Varicella vaccine, making Choice C the correct answer.

Choice D reason:

Haemophilus influenza (Hib) The Haemophilus influenza (Hib) vaccine is usually given to infants starting at 2 months of age and is administered in multiple doses. By 4 years old, the child would have completed the primary series of the Hib vaccine. Therefore, there is no need to administer this vaccine again.

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A nurse is assisting in the admission of a client who had recently given birth and is presenting to the emergency department with acute opioid toxicity. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a child who is receiving IV cefuroxime when the child begins to have difficulty breathing. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is preparing to administer immunizations to a 4-year-old child who is up to date on current immunizations. Which of the following immunizations should the nurse plan to administer?

Correct Answer is C

Explanation

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