You are the PACU nurse that is caring for a client who has been receiving frequent doses of IV Morphine Sulfate, and opioid pain medication, for post-operative pain. Upon reassessment of the patient you find them unarousable with a decreased level of consciousness, snoring respirations at 10 breaths per minute, and an oxygen saturation of 89%. What should be your first intervention?

Administer oxygen at 4 liters per minute via nasal cannula

Administer Naloxone via IV push

Open the patient's airway with a head tilt.

Place them in the shock position with legs elevated

Answer and Explanation

The Correct Answer is B

A. Administering oxygen is important, but the priority is reversing the opioid-induced respiratory depression with naloxone. Oxygen alone will not address the underlying cause of the decreased level of consciousness.
B. Administering naloxone (Narcan) is the priority intervention because it is an opioid antagonist that will reverse the effects of morphine and other opioids, improving respiratory function and consciousness.
C. Opening the airway is important, but the primary issue here is opioid overdose, which requires naloxone administration for reversal of respiratory depression.
D. Placing the patient in the shock position is not indicated in this scenario. The focus should be on reversing opioid toxicity, not on positioning for shock.

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Correct Answer is C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

A. Urine output of 32 mL/hour. B. Confusion and disorientation. C. Blood pressure of 106/82. D. 2+ pedal edema bilaterally.

Correct Answer is B

Explanation

A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is recovering from a lower extremity amputation complains of tingling and "shooting" pain in the amputated extremity. The nurse knows that which of the following is true about this type of pain?

Correct Answer is C

Explanation

The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Correct Answer is B

Explanation

Which of the following is a potential complication for a client whose potassium level is 6.5 mEq/L?

A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

The nurse is caring for a pediatric client who experienced a "greenstick" fracture. The client's mother asks the nurse what it means to have this type of fracture. Which of the following statements should the nurse make?

The nurse is providing education to a client newly diagnosed with gastroesophageal reflux disease (GERD). The nurse knows that the teaching was effective when the client states they should eat which of the following foods?

The nurse is caring for a client who was admitted for a closed femur fracture. Which of the following signs and symptoms would alert the nurse that the client is experiencing compartment syndrome?