The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?
Get the defibrillator to the patient’s bedside and open the crash cart.
Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.
Administer naloxone intranasally if there is not an IV catheter in place.
Contact the patient’s parents or legal guardian for consent to treat.
The Correct Answer is B
The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.
Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart
While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.
Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone
This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.
Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place
While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.
Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat
Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: “I’d rather be dead than live like this. I do not want to be alive.”
This statement reflects suicidal ideation, which is a common symptom of major depressive disorder (MDD). Individuals with MDD often experience feelings of hopelessness and worthlessness, leading them to believe that life is not worth living. Suicidal thoughts are a serious concern and require immediate attention and intervention.
Choice B Reason: “If I can just keep ignoring my feelings, I’ll be fine.”
This statement indicates a form of denial or avoidance, which is also common in individuals with MDD. People with depression may try to ignore or suppress their feelings in an attempt to cope with their condition. However, this approach is generally ineffective and can lead to worsening symptoms over time.
Choice C Reason: “I deserve to be this way. I’ve not accomplished anything important in my life.”
Feelings of worthlessness and excessive guilt are hallmark symptoms of MDD. Individuals with depression often have a negative self-view and believe that they are failures or that they deserve to suffer. This distorted thinking pattern can significantly impact their overall well-being and quality of life.
Choice D Reason: “This is a bad episode, but I will be well soon.”
This statement reflects a more optimistic outlook, which is less common in individuals with MDD. While some people with depression may have moments of hope, the pervasive nature of the disorder typically leads to a more negative and hopeless perspective. Therefore, this choice is less likely to be heard during an intake assessment for MDD.
Choice E Reason: “I am determined to fight this episode and get through it.”
Similar to choice D, this statement indicates a positive and proactive attitude towards managing depression. While determination and resilience are important for recovery, they are not typically expressed by individuals during the acute phase of MDD. This choice is also less likely to be heard during an intake assessment for MDD.
Correct Answer is ["2"]
Explanation
Step 1: Identify the dosage required and the concentration available.
- Required dosage: 40 mg
- Available concentration: 20 mg/mL
Step 2: Calculate the volume to be administered.
- Volume to be administered = Required dosage ÷ Available concentration
- Volume to be administered = 40 mg ÷ 20 mg/mL
Step 3: Perform the division.
- Volume to be administered = 40 ÷ 20
- Volume to be administered = 2 mL
Step 4: Round the answer to the nearest whole number (if necessary).
- Volume to be administered = 2 mL (no rounding needed)
The nurse should administer 2 mL.
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