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 B
Explanation
Choice A reason: Monitoring for signs of sodium and fluid retention is not relevant to this situation, as broad spectrum antibiotics do not affect sodium or fluid balance. Sodium and fluid retention may be caused by other conditions such as heart failure, kidney disease, or liver disease.
Choice B reason: Obtaining wound and blood specimens for culture and sensitivity is most important before administering the first dose of a broad spectrum antibiotic, as this can help identify the specific type and strain of bacteria causing the infection and determine which antibiotic is most effective against it. Broad spectrum antibiotics are effective against a wide range of bacteria, but they may also kill beneficial bacteria and increase the risk of resistance or superinfection.
Choice C reason: Obtaining a complete blood count and serum electrolytes is not necessary before administering the first dose of a broad spectrum antibiotic, as these tests do not provide information about the type or severity of infection. A complete blood count may show an elevated white blood cell count or other changes in response to infection, but it does not identify the causative organism. Serum electrolytes may show abnormalities due to dehydration, vomiting, diarrhea, or other factors, but they do not indicate infection.
Choice D reason: Performing irrigation and topical antibiotic application to wound area is not sufficient before administering the first dose of a broad spectrum antibiotic, as this may not reach all sites of infection or eradicate all bacteria. Irrigation and topical antibiotic application may help clean and prevent further contamination of wound area, but they do not replace systemic antibiotic therapy.
Correct Answer is D
Explanation
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.
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