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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Offering the bedpan every 2 hours does not directly stimulate peristalsis. While regular toileting may prevent constipation, it lacks the mechanical or physiological stimulus needed to enhance bowel motility, especially in postoperative patients at risk for paralytic ileus.

Choice B reason: Ambulation promotes peristalsis by stimulating abdominal muscles and increasing intra-abdominal pressure, which encourages bowel motility. Early mobilization post-surgery enhances blood flow to the gastrointestinal tract, reducing the risk of paralytic ileus by counteracting slowed motility from anesthesia or immobility.

Choice C reason: Increasing protein intake supports tissue repair but does not directly stimulate peristalsis. Protein metabolism may increase stool bulk over time, but it lacks the immediate mechanical or neural stimulation needed to prevent or treat paralytic ileus in the postoperative period.

Choice D reason: Decreasing fluid intake can worsen bowel motility by reducing stool hydration, leading to harder stools and increased risk of constipation. Adequate hydration is essential for maintaining soft stool and supporting peristalsis, making this intervention counterproductive.

A. 1.5 tablets B. 2.5 tablets C. 2 tablets D. 1 tablet

Correct Answer is A

Explanation

Choice A reason: Furosemide 60 mg requires 1.5 tablets of 40 mg (60 ÷ 40 = 1.5). Scored tablets allow precise division, ensuring the correct dose. This calculation aligns with safe medication administration principles, delivering the prescribed amount accurately.

Choice B reason: Administering 2.5 tablets (100 mg) exceeds the prescribed 60 mg dose. Overdosing furosemide, a loop diuretic, risks excessive diuresis, leading to dehydration, hypokalemia, or hypotension, making this choice unsafe and incorrect.

Choice C reason: Two tablets (80 mg) also exceed the 60 mg order. This overdose could cause significant fluid and electrolyte imbalances, particularly in vulnerable patients, as furosemide promotes rapid sodium and water excretion, making this choice inappropriate.

Choice D reason: One tablet (40 mg) underdoses the patient, providing only 66.7% of the prescribed 60 mg. Inadequate dosing may fail to achieve therapeutic effects, such as edema reduction or blood pressure control, rendering this choice incorrect.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

Correct Answer is B

Explanation

Physician order reads: Furosemide 60 mg po bid. Available: 40 mg scored tablets. What do you administer to the patient?

Correct Answer is A

Explanation

A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply)

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

There are a variety of medications that are commonly used to promote healthy bowel elimination. Which best describes a bulk-forming agent?

A patient who had a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA?

Which of the following client statements would cause the nurse to further question the client?

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?