A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?

The initial administration of the analgesic.

The decision regarding when to call the healthcare provider.

The documentation of the client's respiratory rate.

The administration of naloxone via IV.

Answer and Explanation

The Correct Answer is B

Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.

Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's

respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.

Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.

Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A Reason: This action requires assessment and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for providing client education and ensuring that the client understands the discharge instructions.

Choice B Reason: This action requires teaching and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for educating the clients about their prescribed dietary changes and assessing their learning needs and readiness.

Choice C Reason: This action requires critical thinking and decision-making skills, which are beyond the scope of practice of the PN. The nurse is responsible for establishing the blood pressure parameters for client monitoring and adjusting them as needed.

Choice D Reason: This action can be safely delegated to the PN, as it involves reinforcing previous teaching done by the nurse. The PN can review the diet information with the client and answer any questions they may have.

A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L). B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5. C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L). D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Correct Answer is A

Explanation

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse (PN)?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which role is responsible for coordinating the progression of this client's care through rehabilitation and discharge?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?

The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?

The nurse determines that an elderly client with pneumonia has a nursing problem of "altered nutrition, less than body requirements." Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?