A nurse is caring for a client in the emergency department (ED)

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Opioid intoxication: The client exhibits classic signs of opioid overdose, including shallow respirations, bradypnea, bradycardia, hypotension, hypothermia, slurred speech, and constricted pupils. These findings, combined with a history of oxycodone use, indicate opioid intoxication requiring immediate intervention.
Obtain a prescription for naloxone: Naloxone is an opioid antagonist that reverses the respiratory depression, sedation, and other life-threatening effects of opioid overdose. Timely administration can prevent respiratory failure and death.
Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low (10/min) with oxygen saturation at 90%, indicating inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and prevent hypoxia while naloxone takes effect.
Pupillary reaction: Monitoring pupillary constriction or dilation helps assess the client’s response to opioid reversal therapy and can indicate ongoing central nervous system depression or improvement.
Respiratory rate: Continuous monitoring of respiratory rate is essential because hypoventilation is the most immediate life-threatening effect of opioid intoxication. Changes indicate whether interventions like naloxone or ventilation are effective.

Rationale for incorrect choices:

Alcohol intoxication: Although the client has a history of alcohol use disorder, the current symptoms of miosis, hypoventilation, and hypotension are more consistent with opioid toxicity rather than acute alcohol intoxication.
Opioid withdrawal: Withdrawal presents with agitation, tachypnea, hypertension, dilated pupils, diaphoresis, and GI upset. This client’s bradycardia, hypotension, and hypoventilation indicate intoxication, not withdrawal.
Stimulant intoxication: Stimulant overdose typically presents with hypertension, tachycardia, hyperthermia, and agitation. The client’s hypotension, bradycardia, and CNS depression are inconsistent with stimulant use.
Anticipate administering clonidine: Clonidine is used for opioid withdrawal management, not acute intoxication. Administering it in this scenario would not address the life-threatening hypoventilation or CNS depression.
Collect a blood sample for ethanol level: While it may be helpful for history, ethanol testing does not address the immediate life-threatening opioid overdose and is not a priority intervention.
Obtain prescription for restraints: There is no indication for restraints. The client’s symptoms are due to CNS depression, and restraints would not improve their condition and could worsen injury risk.
Hyperreflexia: This is a sign of opioid withdrawal or CNS stimulant activity, not opioid intoxication. The client’s deep tendon reflexes are decreased, consistent with CNS depression.
Cardiac arrhythmias: While arrhythmias can occur, there is no evidence in this assessment of dysrhythmias. Monitoring vital signs and oxygenation is more immediately critical.

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Correct Answer is C

Explanation

A. Documenting communication with a provider in the progress notes of the client's medical record: Proper documentation of provider communication is standard nursing practice and does not constitute malpractice. It helps ensure continuity of care and legal protection.

B. Placing a yellow bracelet on a client who is at risk for falls: Implementing fall precautions, such as using a yellow wristband, is an appropriate safety measure and standard of care, not malpractice.

C. Administering potassium via IV bolus: Administering potassium as a rapid IV push is extremely dangerous and can cause cardiac arrest. This action violates the standard of care and constitutes malpractice due to potential harm to the client.

D. Leaving a nasogastric tube clamped after administering oral medication: A nasogastric (NG) tube is often clamped for a short period after administering medication to allow the medication to be absorbed. The nurse's action would only be considered negligent if they left the tube clamped for a prolonged period.

A. Weight gain 2.3 kg (5 lb) B. Frequent nausea C. Breast tenderness D. Persistent headache

Correct Answer is D

Explanation

A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.

B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.

C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.

D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

Correct Answer is C

Explanation

A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

Correct Answer is D

Explanation

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