A client on a morphine PCA pump is noted to be drowsy and lethargic with pinpoint pupils and the following vitals: pulse 84 beats/minute, respiratory rate 10 breaths/minute, blood pressure 90/50 mm Hg. What is the nurse's best action?
Discuss possible opiate dependence with the client's provider.
Note the effectiveness of the analgesia in the client's chart.
Encourage the client to turn over, and cough and take deep breaths.
Prepare to administer naloxone and provide respiratory support.
The Correct Answer is D
a) While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.
b) Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.
c) Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.
d) The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a) Avoiding alcohol and herbal remedies is a correct instruction because they can interact with warfarin and increase the risk of bleeding.
b) Stopping warfarin abruptly without healthcare provider guidance can be dangerous and increase the risk of thrombosis. Signs of bleeding should be reported promptly to the healthcare provider for appropriate management.
c) Being consistent with the intake of leafy greens is important to maintain a stable INR, as these foods contain vitamin K, which can interfere with warfarin.
d) Regular INR monitoring is essential to ensure that the client is within the therapeutic range and to make adjustments to the warfarin dosage if necessary.
Correct Answer is D
Explanation
a) Taking the medication to prevent asthma attacks is an appropriate use and does not require immediate intervention.
b) Using the rescue inhaler twice a month may indicate the need for further evaluation but does not pose an immediate threat.
c) Sleep disturbances are a known side effect of leukotriene blockers and may need attention, but it is not an urgent concern.
d) Expressing suicidal ideation and having a plan for self-harm is a critical situation that requires immediate intervention to ensure the client's safety and well-being.
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