A nurse is caring for a client that was overdosed with fentanyl. The nurse is concerned that the client is experiencing opioid toxicity triad. Which of the following signs indicate that the client is experiencing opioid toxicity triad? (Select All That Apply.).
Coma
Respiratory depression
Dilated pupils
Pinpoint pupils
Correct Answer : A,B,D
A. Coma is a common symptom of opioid toxicity, including toxicity from fentanyl.
B. Respiratory depression is a hallmark of opioid toxicity and can be life-threatening.
C. Dilated pupils are generally associated with stimulant overdose, not opioid toxicity. Opioid toxicity typically causes pinpoint pupils.
D. Pinpoint pupils (miosis) are a classic sign of opioid toxicity and are present in the opioid toxicity triad.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pushing morphine too quickly (within 30 to 60 seconds) can increase the risk of adverse effects.
B. To reduce the risk of respiratory depression, hypotension, and other adverse effects, morphine sulfate should be administered slowly over 1 to 2 minutes when given intravenously.
C. Pushing over 4 to 5 minutes is excessive and unnecessary for morphine IVP administration.
D. Pushing morphine too quickly (4 to 5 seconds) can cause serious complications, including respiratory depression.
Correct Answer is A
Explanation
A. Petechiae is an early sign of acetaminophen toxicity. It indicates a potential bleeding disorder due to liver damage, which can occur from prolonged or high-dose use of acetaminophen.
B. Osteoporosis is not a symptom of acetaminophen toxicity.
C. Pneumonia is unrelated to acetaminophen toxicity and is more likely to occur due to infections.
D. Diaphoresis (sweating) is not a primary early symptom of acetaminophen toxicity, although it could occur in later stages of liver failure.
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