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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) The nurse should hold the administration of oral metoprolol 25 mg if the blood pressure of the patient is 92/44 mmHg, as this indicates hypotension, which can be worsened by the beta blocker effect of metoprolol.

B) A respiratory rate of 26 breaths per minute is within the acceptable range for administering metoprolol.

C) A heart rate of 92 beats per minute is within the acceptable range for administering metoprolol.

D) Holding the administration of metoprolol may be appropriate if the oxygen saturation level is low. Metoprolol is primarily used for heart rate and blood pressure control and may not be the immediate concern in a client with low oxygen saturation. The healthcare provider should be consulted for further guidance.

A. Bradycardia B. Postoperative blood clots C. Impaired wound healing D. Pre-surgical dehydration

Correct Answer is B

Explanation

A) Bradycardia is not typically associated with long-term steroid use; it may be more related to factors like anesthesia or surgical stress.

B) Prolonged steroid use increases the risk of thrombosis, and postoperative blood clots are a concern in individuals with a history of long-term steroid use.

C) Steroids can delay wound healing, but in this context of emergency surgery for a ruptured appendix, the primary concern is often the risk of blood clots.

D) Pre-surgical dehydration is a potential concern but is not specifically related to the client's history of steroid use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these findings would cause the nurse to hold the administration of oral metoprolol 25 mg?

Correct Answer is A

Explanation

A client has had emergency surgery for a ruptured appendix. Before surgery, the client was taking dexamethasone for three years. With the client's steroid use history, for which complication will the nurse monitor in the recovery phase?

Correct Answer is B

Explanation

Which of these situations would cause the nurse to hold a dose of morphine?

When administering medications to infants, it is essential to remember which of the following? (Select all that apply.)

A client with a new diagnosis of atrial fibrillation is receiving a continuous infusion of heparin. Which finding will the nurse report immediately?

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A client is taking a drug that has potential toxic side effects. What will the nurse do?

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A nurse tells a nursing student that glucocorticoids given for rheumatoid arthritis are nearly identical to substances produced naturally by the body. The student remarks that the drug must be very safe. Which response by the nurse is correct?