A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 breaths/minute. The nurse prepares for which priority action at this time?
Assessment of the patient's pain level
Close observation of signs of opioid tolerance
Immediate intubation and artificial ventilation
Administration of naloxone
The Correct Answer is D
A. Assessment of the patient's pain level: While pain assessment is important, the patient's lethargy and shallow respirations indicate a potential opioid overdose, which takes priority.
B. Close observation of signs of opioid tolerance: The patient's symptoms are indicative of opioid overdose, not tolerance.
C. Immediate intubation and artificial ventilation: While respiratory support may eventually be necessary if the patient's condition deteriorates further, administering naloxone to reverse the opioid effects is the initial priority.
D. Administration of naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors, which can rapidly restore normal respiratory function and
consciousness in patients experiencing opioid-induced respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I know that I cannot switch brands of this medication." - This statement indicates an understanding of the importance of consistency in medication use. Phenytoin requires consistent dosing and should not be switched between different brands without consulting a healthcare provider.
B. "I have made an appointment to see my dentist next week." - This statement shows awareness of the need for dental care while taking phenytoin. Phenytoin can cause gum hyperplasia, so regular dental check-ups are recommended.
C. "I will notify my doctor before taking any other medications." - This statement demonstrates understanding of the potential for drug interactions with phenytoin. Phenytoin can interact with many other medications, so it's crucial to consult a doctor before starting any new medications.
D. "I'll be glad when I can stop taking this medicine." - This statement indicates a
misunderstanding about the management of epilepsy. Phenytoin is typically a long-term medication used to control seizures, and it's not usually discontinued unless directed by a healthcare provider. Further teaching is needed to address this misconception.
Correct Answer is D
Explanation
A. Opioids: Opioids typically cause sedation, respiratory depression, and decreased reflexes, which are opposite to the symptoms described.
B. Depressants: Depressants, such as benzodiazepines or alcohol, would likely cause sedation, decreased reflexes, and confusion, but not the symptoms of restlessness, talkativeness, and hyperactive reflexes.
C. Alcohol: While alcohol intoxication can cause confusion, talkativeness, and tachycardia, it is less likely to result in hyperactive reflexes and restlessness as described.
D. Stimulants: Stimulants, such as amphetamines or cocaine, can cause restlessness, hyperactivity, talkativeness, confusion, panic, and tachycardia, matching the symptoms described.
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