A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

Diaphoresis

Pupillary dilation

Chest pain

Hypotension

Answer and Explanation

The Correct Answer is D

Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.

Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.

Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .

Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.

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Correct Answer is D

Explanation

knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.

An explanation for incorrect choices:

A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.

B. Trendelenburg position

is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.

C. Prone position is lying face down, which is not suitable for sigmoidoscopy.

A. Monitor for at least 150 mL of drainage every hour. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Replace the unit when the drainage chamber is full.

Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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