A client who is obtunded arrives in the emergency department with a suspected drug overdose. The client becomes responsive after the administration of IV naloxone, but within a short period, the client's level of consciousness decreases again and the respiratory rate decreases to 6 breaths/minute. Which action should the nurse take first?

Administer an additional dose of naloxone.

Initiate a second intravenous access site.

Prepare to initiate cardiopulmonary resuscitation (CPR).

Determine if results of the drug toxicity screen are available.

Answer and Explanation

The Correct Answer is A

A. Administer an additional dose of naloxone: Naloxone has a shorter half-life than many opioids, leading to the recurrence of respiratory depression once its effects wear off. When signs of opioid toxicity return, the immediate priority is to administer another dose of naloxone to reverse life-threatening respiratory depression and restore adequate ventilation.

B. Initiate a second intravenous access site: While maintaining IV access is important in emergency care, establishing a second IV line is not the most urgent priority when the client’s breathing is dangerously slow. Immediate reversal of respiratory depression takes precedence.

C. Prepare to initiate cardiopulmonary resuscitation (CPR): CPR is indicated if the client has no pulse or is not breathing. Since the client is still breathing, although minimally, and has a pulse, the immediate action should be reversing the opioid effects with naloxone, not starting CPR.

D. Determine if results of the drug toxicity screen are available: While knowing the substances involved can guide further treatment, waiting for lab results would delay the critical intervention needed to treat the acute respiratory depression at this moment.

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Correct Answer is A

Explanation

A. Serum potassium level of 3.8 mEq/L (3.8 mmol/L): Sodium polystyrene sulfonate is given to treat hyperkalemia by exchanging sodium for potassium in the intestines, promoting potassium elimination. A potassium level within the normal range (3.5 to 5.0 mEq/L) indicates that the medication has effectively lowered dangerously high potassium levels.

B. Serum ammonia level of 30 μg/dL (17.62 μmol/dL): Although a normal ammonia level is important for metabolic balance, sodium polystyrene sulfonate does not target ammonia levels. Changes in ammonia are more relevant to liver function issues, not potassium regulation or AKI management.

C. Hemoglobin level of 13.5 g/dL (135 g/L): Hemoglobin levels are important for evaluating anemia, especially in clients with kidney disease, but sodium polystyrene sulfonate does not affect hemoglobin. This value would not demonstrate the drug’s effectiveness.

D. Serum glucose level of 120 mg/dL (6.7 mmol/L): Elevated glucose could be concerning in clients with diabetes or metabolic disorders but is unrelated to the action of sodium polystyrene sulfonate. Glucose levels are not used to assess the effectiveness of this medication.

A. Notify the healthcare provider if anorexia occurs. B. Consume additional sources of potassium. C. Watch for signs of jitteriness or diaphoresis. D. Administer subcutaneously after meals.

Correct Answer is C

Explanation

A. Notify the healthcare provider if anorexia occurs: Anorexia can be a side effect of exenatide, but it is generally mild and often transient. While persistent or severe anorexia should be reported, it is not the most immediate or dangerous concern compared to the risk of hypoglycemia when combining exenatide with a sulfonylurea like glimepiride.

B. Consume additional sources of potassium: Exenatide is not known to cause significant potassium depletion. Hypokalemia is not a common complication with either exenatide or glimepiride therapy, so there is no specific need to focus on increasing potassium intake.

C. Watch for signs of jitteriness or diaphoresis: Combining exenatide with glimepiride significantly increases the risk of hypoglycemia. Symptoms like jitteriness, diaphoresis, shakiness, and confusion are hallmark signs of low blood sugar, making it crucial to educate the client to recognize and manage hypoglycemia promptly.

D. Administer subcutaneously after meals: Exenatide should be administered subcutaneously, but it must be given before meals, typically within 60 minutes prior to eating. Administering it after meals would decrease its effectiveness in controlling postprandial blood glucose spikes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with type 2 diabetes mellitus is managed with glimepiride. The primary healthcare provider (HCP) adds a new prescription for injectable exenatide. Which information is most important for the nurse to teach this client?

Correct Answer is C

Explanation

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