A client is receiving morphine post-operatively for pain control. The unlicensed personal assistant notifies the nurse that the client was sleeping heavily and his/her vital signs were HR 70; RR 10; BP 88/42; O2 Sat 85% in room air. Which of the following interventions would be a priority for the nurse?
Prepare to administer naloxone (Narcan), place the client in Fowler’s, and apply oxygen
Place the client in high Fowler’s position
Apply O2 via nasal cannula
Administer flumazenil IV, apply oxygen, and notify the provider of care
The Correct Answer is A
Choice A reason: Morphine-induced respiratory depression (RR 10, O2 Sat 85%) and hypotension (BP 88/42) indicate opioid overdose. Naloxone reverses opioid effects, while Fowler’s position and oxygen improve ventilation and oxygenation, addressing life-threatening symptoms as the priority.
Choice B reason: High Fowler’s position aids breathing but does not address morphine’s opioid effects causing respiratory depression and hypoxia. Alone, it is insufficient to reverse the underlying cause or stabilize the patient’s critical vital signs.
Choice C reason: Applying oxygen via nasal cannula improves oxygenation but does not reverse morphine’s central nervous system depression causing hypoventilation. It is a supportive measure, not the priority compared to naloxone administration.
Choice D reason: Flumazenil reverses benzodiazepines, not opioids like morphine. Administering it is inappropriate and ineffective for this scenario, and while oxygen is helpful, it is secondary to reversing the opioid overdose with naloxone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Wiping from back to front risks introducing perianal bacteria into the urethra, contaminating the sample. Proper technique involves wiping front to back to minimize contamination, making this statement incorrect and indicative of misunderstanding.
Choice B reason: While menstruation may complicate urine collection, it is not an absolute contraindication. With proper technique (e.g., using a tampon), samples can be collected. This statement reflects a misconception and does not confirm understanding of midstream collection.
Choice C reason: Urine should be sent to the lab promptly or refrigerated to prevent bacterial growth or analyte degradation. Allowing it to cool to room temperature risks inaccurate results, so this statement demonstrates a lack of understanding of proper handling.
Choice D reason: Urinating a small amount into the toilet first flushes out urethral contaminants, ensuring a cleaner midstream sample. This technique is critical for accurate urinalysis or culture, confirming the client’s understanding of the taught procedure.
Correct Answer is D
Explanation
Choice A reason: Offering narcotics immediately without assessing pain details or considering nonpharmacological options is not therapeutic. Pain management requires a tailored approach, evaluating pain characteristics and patient preferences, as narcotics carry risks like respiratory depression, especially post-surgery, necessitating cautious use.
Choice B reason: Dismissing pain based on stable vitals is not therapeutic. Pain is subjective, and normal vitals (e.g., 110/60 mmHg, 60 bpm) don’t negate severe pain. This response invalidates the patient’s experience, potentially eroding trust and delaying effective pain management.
Choice C reason: Stating the patient doesn’t look in pain is dismissive and non-therapeutic. Pain is subjective, and external appearance may not reflect internal experience, especially in stoic patients. This response risks undermining patient trust and delaying appropriate pain relief interventions.
Choice D reason: Asking what the patient wants to try is therapeutic, promoting patient-centered care. It validates the patient’s pain, encourages shared decision-making, and considers both pharmacological and nonpharmacological options, optimizing pain relief while respecting patient autonomy and preferences post-surgery.
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