A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)
pH 7.29
Pa CO2 54
pH 7.51
PaO2 72
Pa CO2 31
Correct Answer : A,B
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Negligence refers to the failure to exercise reasonable care that results in harm to another person. It occurs when a healthcare provider fails to perform their duties according to the standard of care expected in their profession, leading to injury or harm to the patient. In the scenario described, the failure to follow orders for turning and positioning, resulting in pressure injuries, is an example of negligence. Negligence can result from actions (acts of commission) or omissions (acts of omission).
A. Battery refers to the intentional harmful or offensive touching of another person without their consent. In healthcare, battery may occur if a medical procedure is performed on a patient without their informed consent or if a procedure goes beyond the scope of what was consented to. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of battery because it does not involve intentional harm.
C. Assault refers to the intentional threat of harm or the creation of fear of imminent harm in another person. In healthcare, assault may occur if a healthcare provider threatens a patient with harm or performs a procedure without their consent, creating fear or apprehension in the patient. In the context of the scenario provided, the development of pressure injuries due to inadequate turning and positioning is not an example of assault because it does not involve intentional threats or actions creating fear in the patient.
D. A felony is a serious criminal offense punishable by imprisonment or death. It typically involves actions that are considered extremely harmful or dangerous to society. The scenario described does not involve actions that rise to the level of a felony offense.
Correct Answer is D
Explanation
D. Calling the prescribing physician to clarify the order is the most appropriate action in this situation. Direct communication with the physician allows the nurse to express concerns, seek clarification, and ensure that the medication order is appropriate and safe for the client.
A. Administering a medication at a higher than recommended dose could potentially harm the client and is not in line with safe medication administration practices. It's essential to follow the established guidelines and recommendations for medication dosing to avoid adverse effects or complications.
B. Holding the ordered dose and documenting the rationale is an appropriate initial action. This allows the nurse to pause the administration of the medication, prevent potential harm to the client, and provide a clear record of the decision-making process. Holding the dose also provides an opportunity for further clarification with the prescribing physician.
C. While reporting a mistake to the pharmacy is important, it may not be the most immediate action to take when dealing with a higher than recommended dose of medication. Direct communication with the prescribing physician is necessary to clarify the order and ensure appropriate action is taken promptly.
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