A nurse in an emergency department is administering naloxone to a client who had a heroin overdose.
The nurse should identify which of the following assessment findings as an indication that the medication is reversing the effects of the opioid overdose?
Decreased temperature.
Polyuria.
Bradycardia.
Increased respiratory rate.
The Correct Answer is D
Choice A rationale:
Decreased temperature is not a typical sign of naloxone reversing the effects of an opioid overdose. Opioid overdose commonly leads to respiratory depression and hypoxia, but it does not significantly affect body temperature. Naloxone works by binding to the same receptors in the brain that opioids bind to, thereby reversing the effects of the overdose. The primary signs of successful reversal include improved respiratory rate and increased alertness, not changes in body temperature.
Choice B rationale:
Polyuria (excessive urination) is not a specific indicator of naloxone effectiveness. Opioid overdose and naloxone administration primarily affect the central nervous system and respiratory function, not urinary output. Naloxone's effects are more evident in the client's level of consciousness, respiratory rate, and overall responsiveness.
Choice C rationale:
Bradycardia (slow heart rate) is not an expected indicator of naloxone effectiveness. Opioid overdose typically causes respiratory depression, leading to a decreased respiratory rate and oxygen saturation. Naloxone works by reversing this respiratory depression and improving ventilation. Consequently, increased respiratory rate, not heart rate, is a more relevant indicator of naloxone's effectiveness in reversing opioid overdose.
Choice D rationale:
This is the correct answer. Increased respiratory rate is a key indicator that naloxone is reversing the effects of an opioid overdose. Opioid overdose depresses the respiratory system, leading to slow and shallow breathing. Naloxone, as an opioid receptor antagonist, rapidly reverses this effect, leading to a noticeable increase in the client's respiratory rate. Monitoring for improved breathing and increased oxygen saturation is crucial to assessing the effectiveness of naloxone in treating opioid overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding gums are common during pregnancy due to hormonal changes that make gums more sensitive and prone to bleeding. This is not typically a sign of a serious condition and can usually be managed with good oral hygiene.
B. Faintness or lightheadedness upon rising is common in pregnancy due to blood pressure changes. This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
C. Swelling of the face during pregnancy can be an early sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage. This is a concerning symptom that requires immediate evaluation by a healthcare provider.
D. Urinary frequency is a common and usually benign symptom during pregnancy, especially in the first and third trimesters due to hormonal changes and pressure on the bladder. It does not typically require urgent reporting unless accompanied by other symptoms such as pain or burning during urination, which could indicate a urinary tract infection.
Correct Answer is A
Explanation
A. Correct. At 12 weeks of gestation, the nurse should position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
B. Fundal height measurement is used to assess uterine growth and is not applicable for assessing fetal heart rate.
C. Placing the client in a side-lying position is not necessary for assessing fetal heart rate at 12 weeks of gestation.
D. Leopold maneuvers are used to determine fetal position and lie and are not directly related to auscultating the fetal heart rate.
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