A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.

Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.

Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.

Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.

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Correct Answer is B

Explanation

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

A. Loperamide should not be used if diarrhea is infectious. B. You can take loperamide until the diarrhea stops. C. Loperamide has no side effects. D. Loperamide should not stop this type of diarrhea.

Correct Answer is A

Explanation

Choice A Reason:

Loperamide should not be used if diarrhea is infectious is correct. Loperamide is an antidiarrheal medication that works by slowing down gut movement. However, if the diarrhea is caused by an infection, such as from spoiled food, it is important to allow the body to expel the infectious agents. Using loperamide in such cases can prolong the infection and potentially worsen the condition.

Choice B Reason:

You can take loperamide until the diarrhea stops is incorrect. While loperamide can be effective for non-infectious diarrhea, it is not recommended for infectious diarrhea. Stopping the diarrhea prematurely can trap the infectious agents in the intestines, leading to more severe symptoms.

Choice C Reason:

Loperamide has no side effects is incorrect. Loperamide can have side effects, including constipation, dizziness, and abdominal pain. It is important to use this medication under the guidance of a healthcare provider, especially in cases of infectious diarrhea.

Choice D Reason:

Loperamide should not stop this type of diarrhea is incorrect. While it is true that loperamide should not be used for infectious diarrhea, the statement is misleading. Loperamide can stop diarrhea, but it is not appropriate for all types of diarrhea, particularly those caused by infections.

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A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client with numerous episodes of watery diarrhea. The client reports eating some spoiled deli meat earlier in the day. The client asks if they should take loperamide (Imodium) to stop the diarrhea. What would be an appropriate response from the nurse?

Correct Answer is A

Explanation

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