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 D
Explanation
Choice A reason: Hypertension is not a typical sign of an allergic reaction to piperacillin-tazobactam, which is an antibiotic. It may be caused by other factors, such as pain, anxiety, or renal impairment. The nurse should monitor the client's blood pressure and report any abnormal findings.
Choice B reason: Bradycardia is not a common or serious side effect of piperacillin-tazobactam. It may be related to other medications, such as beta-blockers, or underlying cardiac conditions. The nurse should check the client's pulse and rhythm and report any changes.
Choice C reason: Pupillary constriction is not associated with piperacillin-tazobactam or an allergic reaction. It may be caused by other drugs, such as opioids, or neurological disorders. The nurse should assess the client's level of consciousness and pupillary response.
Choice D reason: Scratchy throat is a possible sign of anaphylaxis, which is a severe and potentially fatal allergic reaction to piperacillin-tazobactam or any other drug. Other symptoms may include hives, swelling, wheezing, or hypotension. The nurse should stop the infusion immediately and call for help.
Correct Answer is ["200"]
Explanation
The correct answer is 200 mL/hr.
Explanation: To calculate the infusion rate, the nurse should use the formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
In this case, the volume is 200 mL and the time is 1 hour. Therefore,
Infusion rate (mL/hr) = 200 mL / 1 hr
Infusion rate (mL/hr) = 200 mL/hr
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