The nurse administers naloxone to a patient with opioid-induced respiratory depression.
An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive.
What action should the nurse take?

Administer a second dose of naloxone.

Prepare to assist with chest tube insertion.

Determine Glasgow Coma Scale score.

Initiate cardiopulmonary resuscitation (CPR). .

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: Initiate cardiopulmonary resuscitation (CPR).

Choice D rationale: The patient's respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression, which requires immediate intervention. CPR is the priority action to maintain circulation and oxygenation while awaiting further interventions.

Choice A rationale: Administering a second dose of naloxone may be necessary to counteract the effects of opioids. However, in this case, the patient's condition has severely deteriorated, and immediate resuscitation efforts take priority.

Choice B rationale: Preparing to assist with chest tube insertion is not the appropriate action in this situation. Chest tube insertion is used to treat conditions like pneumothorax or pleural effusion, which are not indicated in this scenario.

Choice C rationale: Determining the Glasgow Coma Scale score is useful for assessing the patient's level of consciousness but should not be the first action in this case. Ensuring adequate circulation and oxygenation through CPR is the priority.

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Correct Answer is A

Explanation

Choice A rationale

Hypertension is a condition that should be reported to the healthcare provider before administering phenylephrine. Phenylephrine is a decongestant used to relieve nasal discomfort caused by colds, allergies, and hay fever. It works by shrinking swollen nasal mucous membranes, which relieves nasal congestion. However, it can cause a rise in blood pressure, which could be dangerous for patients with hypertension.

Choice B rationale

Bronchitis is not a contraindication for phenylephrine. However, if the patient has a chronic respiratory condition like bronchitis, it’s always a good idea to discuss any new medications with the healthcare provider.

Choice C rationale

Diarrhea is not a contraindication for phenylephrine. Phenylephrine is not known to cause or worsen diarrhea.

Choice D rationale

Edema is not a contraindication for phenylephrine. However, if the patient has a history of heart disease or high blood pressure, which can sometimes cause edema, they should inform their healthcare provider.

A. St. John’s Wort can decrease plasma concentrations of cyclosporine. B. Consumption of St. John’s Wort can reduce the patient’s sodium intake. C. Adding the herb can decrease the need for corticosteroids. D. The patient probably used this herb to treat depression.

Correct Answer is A

Explanation

Choice A rationale

St. John’s Wort is known to interact with many prescription drugs, including cyclosporine, a medication often given to transplant patients to prevent organ rejection. St. John’s Wort can decrease plasma concentrations of cyclosporine, thus endangering the success of organ transplantations.

Choice B rationale

There is no evidence to suggest that consumption of St. John’s Wort can reduce the patient’s sodium intake.

Choice C rationale

Adding the herb does not decrease the need for corticosteroids. In fact, it can interact with many medications and cause serious complications.

Choice D rationale

While St. John’s Wort is often used to treat depression, in the context of a patient who has undergone a renal transplant, the most significant information is its potential to interact with cyclosporine and endanger the success of the transplant.

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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours.What patient condition should the nurse report to the healthcare provider before administering the medication?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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The nurse administers naloxone to a patient with opioid-induced respiratory depression.
An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive.
What action should the nurse take?