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 A

Explanation

The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.

Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.

A. Echinacea B. Flaxseed powder C. Probiotics D. Ginkgo biloba

Correct Answer is D

Explanation

Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

Reasons, why the other choices are not answers, are:

A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.

B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.

C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.

In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

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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 assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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