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 B

Explanation

A) Allopurinol inhibits the synthesis of uric acid, preventing its formation.

B) Colchicine is typically used for gout flares and reduces inflammation but is not usually taken concurrently with probenecid and allopurinol. NSAIDs or corticosteroids are often used for pain control during acute attacks.

C) Colchicine is known for its anti-inflammatory properties but does not prevent uric acid synthesis or facilitate its elimination.

D) Probenecid increases the excretion of uric acid in the urine.

A. "The negative feedback loop prevents side effects." B. "As long as the drug is taken as prescribed, side effects usually do not occur." C. "By interrupting the inflammatory process, these drugs inhibit side effects." D. "Side effects can occur and are dependent on the dose and duration of treatment."

Correct Answer is D

Explanation

a) While the negative feedback loop plays a role in the body's natural regulation of corticosteroids, it does not eliminate the potential for side effects when exogenous glucocorticoids are administered.

b) Taking the drug as prescribed does not guarantee the absence of side effects. Side effects are inherent to glucocorticoid therapy and can occur even with appropriate use.

c) Interrupting the inflammatory process does not directly inhibit side effects. The anti inflammatory action is the therapeutic effect, but it does not eliminate the potential for side effects.

d) Glucocorticoids, even those produced naturally by the body, can cause side effects, and the likelihood and severity of these side effects depend on the dose and duration of treatment. Regular monitoring and appropriate management are essential.

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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

A client who is suffering from an acute gout attack wants to know how colchicine differs from probenecid and allopurinol in its actions. Which of these statements shows the need for further teaching regarding the purpose and use of these medications?

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

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