A nurse is caring for a client who has respiratory depression from an opioid administration.
After administering naloxone to the client, which of the following findings should the nurse expect?
Increased pain.
Somnolence.
Hyperglycemia.
Hypoventilation.
The Correct Answer is A
The correct answer is A. Increased pain.
Choice A reason: Naloxone is an opioid antagonist that, when administered, reverses the effects of opioids. Since opioids provide analgesia, their reversal will lead to the return of pain sensation. The normal pain response varies widely among individuals and depends on the type and amount of opioid the patient received, as well as their pain threshold and tolerance.
Choice B reason: Somnolence, or drowsiness, is a common effect of opioid administration. Naloxone works by displacing opioids from their receptors, which should counteract the sedative effects of opioids and reduce somnolence. Therefore, after naloxone administration, the nurse should not expect somnolence as a finding.
Choice C reason: Hyperglycemia, or high blood sugar, is not a direct effect of naloxone administration. While some studies suggest that naloxone may affect blood glucose levels under certain conditions, such as in the case of tramadol overdose, it does not typically cause hyperglycemia. Normal blood glucose levels range from 70 to 99 mg/dL fasting, and up to 140 mg/dL two hours after eating.
Choice D reason: Hypoventilation, or reduced breathing rate and depth, is caused by opioid administration. Naloxone’s role is to reverse this effect, restoring normal breathing rates. The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Advance directives are voluntary and revocable; clients can change their decisions at any time as long as they are mentally competent.
Choice B rationale: Discussing advance directives with family ensures clarity, reduces future conflict, and supports informed decision-making aligned with the client’s wishes.
Choice C rationale: Witnesses are typically required, but a partner’s presence is not legally mandated unless designated as a healthcare proxy.
Choice D rationale: Notarization is not universally required; validity depends on state laws, and many jurisdictions accept signed and witnessed documents without attorney involvement.
Correct Answer is B
Explanation
Choice A rationale:
Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.
Choice B rationale:
A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.
Choice C rationale:
A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.
Choice D rationale:
Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.
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