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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU).

Exhibits

A nurse has assessed the postoperative client. Which of the following interventions are needed immediately?
(Select All that Apply.)

Give naloxone 0.2 mg IV STAT

Bag-valve-mask (BVM) ventilations

Chest compressions

Defibrillation

Incentive spirometry

Chest physiotherapy (CPT)

Give 2 units of packed red blood cells (PRBCs)

Obtain crash cart

Correct electrolyte imbalance(s)

Give morphine sulfate 2 mg IV x 1 STAT

Answer and Explanation

Correct Answer : A,B,H

A. Give naloxone 0.2 mg IV STAT
The client has received multiple opioids (fentanyl + morphine) and is now increasingly somnolent, minimally responsive, with shallow respirations and low oxygen saturation. These are classic signs of opioid-induced respiratory depression, and naloxone (an opioid antagonist) should be administered immediately.

B. Bag-valve-mask (BVM) ventilations
The client has shallow respirations and poor oxygenation (SpO₂ dropped to 92%) and is minimally responsive. BVM is essential to maintain oxygenation and ventilation while naloxone takes effect or if apnea develops.

C. Chest compressions
There is no indication of cardiac arrest. The client still has a pulse and blood pressure, though hypotensive.

D. Defibrillation
There is no mention of a shockable rhythm (e.g., V-fib or pulseless V-tach). Defibrillation is not indicated for respiratory depression or somnolence.

E. Incentive spirometry
The client is minimally responsive and unable to cooperate with incentive spirometry. This is used post-op for alert clients to prevent atelectasis, not for unconscious or sedated patients.

F. Chest physiotherapy (CPT)
Not appropriate for this case. CPT is used for mucus clearance in conditions like COPD or pneumonia, not for opioid-induced respiratory depression.

G. Give 2 units of packed red blood cells (PRBCs)
There is no sign of active bleeding or anemia. Hemoglobin was not reported to be low, and there are no signs of hemorrhagic shock.

H. Obtain crash cart
The client is decompensating rapidly - lethargy, hypotension, and respiratory depression could progress to respiratory or cardiac arrest. Having the crash cart ready ensures that resuscitation medications and defibrillation (if needed) are available without delay.

I. Correct electrolyte imbalance(s)
There is no data provided suggesting an electrolyte imbalance. This is not a priority in the setting of opioid overdose with respiratory compromise.

J. Give morphine sulfate 2 mg IV x 1 STAT
This would worsen the client’s condition by increasing opioid load in someone already experiencing opioid toxicity. It’s absolutely contraindicated.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Avoid acetaminophen.
Acetaminophen is safe to use; NSAIDs should be avoided due to bleeding risk.

B. Use a soft toothbrush.
Prevents gum bleeding and injury.

C. Stop anticoagulant therapy when symptoms subside.
Dangerous. Anticoagulation must be continued as prescribed to prevent recurrence.

D. Avoid high-impact activities.
Helps reduce the risk of trauma and bleeding.

E. Wear a medical alert bracelet.
Informs healthcare providers in emergencies that the client is on anticoagulants.

A. "When my baby is born, they can receive Medicaid as well." B. "Medicaid benefits are the same for everyone in the United States." C. "My income level does not impact whether or not I can receive Medicaid." D. "Medicaid is a federal-run health insurance program."

Correct Answer is A

Explanation

A. "When my baby is born, they can receive Medicaid as well."
Medicaid covers pregnant individuals and their infants for a period after birth, depending on income and state policy.

B. "Medicaid benefits are the same for everyone in the United States."
Incorrect. Medicaid is administered at the state level, and benefits vary.

C. "My income level does not impact whether or not I can receive Medicaid."
Medicaid eligibility is income-based.

D. "Medicaid is a federal-run health insurance program."
Medicaid is funded by both federal and state governments, but administered by individual states.

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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU). Exhibits A nurse has assessed the postoperative client. Which of the following interventions are needed immediately? (Select All that Apply.)

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Correct Answer is ["B","D","E"]

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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU).

Exhibits

A nurse has assessed the postoperative client. Which of the following interventions are needed immediately?
(Select All that Apply.)