A nurse is teaching a newly licensed nurse about assessing a client who received naloxone to treat opioid toxicity. The nurse should include that which of the following findings indicate the intervention is effective?

Cheyne-stokes respirations

Substernal retractions during respirations

Increased respirations

Kussmaul respirations

Answer and Explanation

The Correct Answer is C

Naloxone is an opioid antagonist used to rapidly reverse the effects of an opioid overdose, which often includes severely slowed or stopped breathing.

CheyneStokes respirations (A) and Kussmaul respirations (D) are abnormal breathing patterns that are not indicative of effective naloxone treatment.
Substernal retractions (B) indicate difficulty breathing, which would not suggest that the naloxone has been effective.
Effective naloxone intervention is typically indicated by the restoration of normal breathing patterns in a person who has experienced opioid toxicity.

A-Cheyne stokes respirations is due to conditions such as stroke, brain injury

B-Substernal retraction occur in respiratory distress due to pulmonary conditions such as pneumonia D-Kussmaul breathing is found in diabetes ketoacidosis

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Correct Answer is D

Explanation

The client most at risk for hypokalemia among the ones listed would be D, the client who has a nasogastric (NG) tube to suction. Hypokalemia, or low potassium levels in the blood, can occur due to excessive loss of potassium in the gastrointestinal tract. An NG tube to suction can cause significant potassium loss because it removes gastric contents, which include potassium. Other factors that can contribute to hypokalemia include prolonged diarrhea, vomiting, and certain medications that increase urination or cause potassium to shift out of the bloodstream. It's important for nurses to monitor the electrolyte levels of clients with NG tubes to suction and manage their potassium levels appropriately to prevent complications.

Other drainage tubes do not contribute to electrolytes loss

A. Give the ordered KCL as prescribed. B. Call the prescribing physician and inform her of the client's serum potassium level results. C. Call the lab to verify the client's results. D. Omit the KCL dose and document it was not given.

Correct Answer is B

Explanation

A potassium level of 6.0 mEq/L is considered to be mild hyperkalemia. Hyperkalemia can be dangerous and usually requires immediate treatment, especially if it is accompanied by symptoms or significant changes from the client's baseline. The appropriate action would be to inform the prescribing physician of the client's serum potassium level to receive further instructions, which may include omitting the dose or adjusting the treatment plan.

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A nurse is teaching a newly licensed nurse about assessing a client who received naloxone to treat opioid toxicity. The nurse should include that which of the following findings indicate the intervention is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 6.0 mEq/L Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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