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). .

None

Answer and Explanation

The Correct Answer is A

The patient’s respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression and a life-threatening emergency. Naloxone was administered an hour ago, but its effects typically last 30–90 minutes, and opioid effects may outlast it, especially with long-acting opioids. The priority is to address the immediate threat to life.

A. Administer a second dose of naloxone: Naloxone reverses opioid-induced respiratory depression. Given the recurrence of severe symptoms, a repeat dose is appropriate to counteract potential ongoing opioid effects.
B. Prepare to assist with chest tube insertion: This is irrelevant, as there’s no indication of pneumothorax or other conditions requiring a chest tube.
C. Determine Glasgow Coma Scale score: While assessing neurological status is useful, it’s not the priority when the patient is in acute respiratory failure.
D. Initiate cardiopulmonary resuscitation (CPR): CPR is indicated for cardiac arrest, but the patient has a respiratory rate (albeit critically low) and no mention of absent pulse, so CPR is not yet warranted.

The most appropriate action is to administer a second dose of naloxone to reverse the opioid-induced respiratory depression, followed by close monitoring and supportive care (e.g., oxygen, ventilation support if needed).

Final Answer: A. Administer a second dose of naloxone.

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Correct Answer is C

Explanation

Choice A rationale

While a family history of mental illness is important information to obtain when planning care for a client with major depression, it is not the most important information when the client is receiving a new prescription for duloxetine. Family history can provide insight into the client’s risk factors for depression, but it does not directly impact the safety or efficacy of duloxetine.

Choice B rationale

Weight change in the last month is not the most important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine. While significant weight changes can be a symptom of depression and should be monitored, they do not directly impact the safety or efficacy of duloxetine.

Choice C rationale

Liver function laboratory results are the most important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine.

Duloxetine is metabolized in the liver, and abnormal liver function can affect the metabolism and elimination of the drug, potentially leading to increased side effects or decreased effectiveness. Therefore, it is crucial to assess liver function before and during treatment with duloxetine.

Choice D rationale

While recent use of other antidepressants is important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine, it is not the most important information. This information can help prevent drug interactions and serotonin syndrome, a potentially life-threatening condition. However, liver function has a more direct impact on the safety and efficacy of duloxetine.

Correct Answer is ["200"]

Explanation

The correct answer is 200 mL/h.

Step 1: The client has been prescribed ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour.

Step 2: The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D5W) 200 mL12. Step 3: To calculate the infusion rate, the nurse should use the formula: Infusion rate (mL/hr)

= Volume (mL) / Time (hr)3.

Step 4: In this case, the volume is 200 mL and the time is 1 hour. Step 5: Therefore, Infusion rate (mL/hr) = 200 mL ÷ 1 hr.

Step 6: Infusion rate (mL/hr) = 200 mL/hr.

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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

The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. What information is most important for the nurse to obtain?

Correct Answer is C

Explanation

A client has been prescribed ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D5W) 200 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["200"]

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?