The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?
Prepare to assist with chest tube insertion.
Initiate cardiopulmonary resuscitation (CPR).
Determine Glasgow Coma Scale score.
Administer a second dose of naloxone.
The Correct Answer is D
Choice A reason: Chest tube insertion is not indicated for respiratory depression caused by opioid overdose. It is a procedure used to treat pneumothorax, hemothorax, or pleural effusion.
Choice B reason: CPR is not the first-line intervention for respiratory depression. It is only indicated when the client has no pulse or signs of life.
Choice C reason: Glasgow Coma Scale score is a tool to assess the level of consciousness of a client. It is not an intervention that can reverse respiratory depression.
Choice D reason: Naloxone is an opioid antagonist that can reverse the effects of opioid overdose. It has a short half-life and may need to be repeated if the client's condition does not improve or worsens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: Acetylcysteine is a mucolytic agent that breaks down mucus and makes it easier to cough up or suction out. This helps to clear the airways and improve oxygenation. The nurse should expect to see increased sputum production after administering acetylcysteine and provide frequent suctioning as needed.
Choice A reason: Bronchodilation and wheezing are not therapeutic responses of acetylcysteine, but rather possible adverse effects. Acetylcysteine can cause bronchospasm or bronchoconstriction in some clients, especially those with asthma or chronic obstructive pulmonary disease (COPD). The nurse should monitor the client's breath sounds and oxygen saturation and report any signs of respiratory distress.
Choice B reason: Unpleasant smell when using the medication is not a therapeutic response of acetylcysteine, but rather a common side effect. Acetylcysteine has a rotten egg odor that can be unpleasant for both the client and the nurse. The nurse can minimize this by using a mouthwash or a flavored lozenge before and after administering acetylcysteine.
Choice D reason: Hypotension is not a therapeutic response of acetylcysteine, but rather a rare but serious adverse effect. Acetylcysteine can cause vasodilation or hypovolemia in some clients, leading to low blood pressure and shock. The nurse should monitor the client's vital signs and report any signs of hypotension.
Correct Answer is ["42"]
Explanation
The correct answer is 42gtt/min.
To calculate the infusion rate, use the formula:
gtt/min = (volume in mL x drop factor in gtt/mL) / time in min
Plug in the given values:
gtt/min = (500 mL x 10 gtt/mL) / 120 min
gtt/min = 5000 gtt / 120 min
gtt/min = 41.67 gtt/min
Round to the nearest whole number:
gtt/min = 42 gtt/min
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