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 C

Explanation

a) Taking digoxin at bedtime is not a critical instruction. The important aspect is to take it consistently at the same time each day.

b) A diet high in bran, fiber, and calcium is not specifically related to digoxin administration. Digoxin has specific dietary considerations related to potassium levels.

c) Checking the pulse is crucial for a client taking digoxin, as it helps monitor for potential toxicity. Digoxin can cause bradycardia, and the pulse rate is an essential parameter to assess before administering each dose.

d) While monitoring the heart rate is important, setting a specific threshold (e.g., not taking digoxin if the heart rate exceeds 90 beats per minute) is not a standard recommendation. It's generally more nuanced and individualized.

A. "I can rotate acetaminophen with ibuprofen if needed for pain control, so I don't take too much of either one." B. "If I still have pain 10 minutes after taking 1000 mg of acetaminophen, I should take two of oxycodone-acetaminophen." C. "Taking more than 4000 mg of acetaminophen in a day can cause liver problems." D. "Taking acetaminophen often could mask any infection-related fevers I might have."

Correct Answer is D

Explanation

a) The statement about rotating acetaminophen with ibuprofen for pain control demonstrates an understanding of the principles of multimodal pain management and is appropriate.

b) The statement about taking two oxycodone-acetaminophen tablets if pain persists after a certain time frame is appropriate and reflects awareness of appropriate pain management strategies.

c) The statement about the maximum daily dose of acetaminophen and its potential to cause liver problems is accurate and indicates good knowledge.

d) The statement about acetaminophen masking infection-related fevers is incorrect. While acetaminophen can reduce fever, it does not mask the presence of an infection. This statement indicates a need for further teaching.

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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

What should the nurse include in a client's discharge teaching when going home with a prescription for digoxin 0.125 mg by mouth once daily?

Correct Answer is C

Explanation

A client who is recovering from total knee surgery is preparing for discharge. Which of these statements indicates the client needs further teaching?

Correct Answer is D

Explanation

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