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 A reason: A cool, humidified air is not relevant for this client, as it does not affect the eyes or vision. A cool, humidified air may be beneficial for clients with respiratory conditions, such as asthma or bronchitis.
Choice B reason: A quiet, restful environment is not specific for this client, as it does not address the effects of mydriatic medication on the eyes or vision. A quiet, restful environment may be helpful for clients with stress, anxiety, or insomnia.
Choice C reason: A dimly lit room is the best environment for this client, as it reduces the glare and discomfort caused by mydriatic medication. Mydriatic medication is a type of eye drop that dilates the pupils and prevents them from constricting in response to light. This can improve the examination of the retina and optic nerve, but it also makes the eyes more sensitive to light and reduces the ability to focus on near objects.
Choice D reason: A warm room temperature is not necessary for this client, as it does not affect the eyes or vision. A warm room temperature may be comfortable for clients with cold intolerance, such as hypothyroidism or Raynaud's phenomenon.
Correct Answer is C
Explanation
Choice A reason: Encouraging an increase in oral intake is not necessary in this situation, as dark urine is not a sign of dehydration or fluid imbalance. Dark urine may be caused by certain foods, medications, or medical conditions, but it does not indicate a need for more fluids.
Choice B reason: Measuring the client's urinary output is not relevant to this situation, as dark urine is not a sign of urinary retention or obstruction. Urinary output may vary depending on fluid intake, activity level, or other factors, but it does not reflect urine color.
Choice C reason: Explaining that color change is normal is the appropriate action to take, as dark urine is a common and harmless side effect of carbidopa/levodopa, which is a combination drug used to treat Parkinson's disease by increasing dopamine levels in the brain. Carbidopa/levodopa can cause urine to turn brown, black, or red, but this does not affect the function or health of the kidneys or bladder.
Choice D reason: Obtaining a specimen for a urine culture is not necessary in this situation, as dark urine is not a sign of infection or inflammation. A urine culture may be indicated if the client has symptoms such as fever, pain, burning, frequency, or urgency, but it does not diagnose urine color
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