A nurse is assessing a client who is receiving opioid pain medication. Which respiratory rate finding requires the nurse's immediate intervention?
Respiratory rate of 20 breaths/min
Respiratory rate of 8 breaths/min
Respiratory rate of 18 breaths/min
Respiratory rate of 14 breaths/min
The Correct Answer is B
Rationale:
A. The normal adult respiratory rate ranges from 12 to 20 breaths per minute. A rate of 20 is at the upper end of normal and generally does not indicate respiratory compromise. While the nurse should continue routine monitoring, no immediate intervention is necessary in this context.
B. This is below the normal range and constitutes bradypnea, which is particularly concerning in a client receiving opioids. Opioid medications, such as morphine, hydromorphone, or fentanyl, can depress the central nervous system, leading to slowed or inadequate respirations. A respiratory rate of 8 breaths per minute indicates significant respiratory depression, which can result in hypoxia (low oxygen levels), hypercapnia (excess carbon dioxide), altered mental status, and potentially respiratory arrest if not addressed immediately. The nurse must take urgent action, which includes stopping or reducing the opioid if appropriate, stimulating the client to breathe, administering supplemental oxygen, monitoring oxygen saturation and vital signs, and notifying the prescribing provider. Early recognition and intervention are critical to prevent life-threatening complications.
C. This falls within the normal adult range and does not indicate respiratory compromise. The nurse should continue standard monitoring but no immediate action is required.
D. This is also within the normal adult range and reflects adequate ventilation. It does not necessitate immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. This term describes a slower-than-normal respiratory rate. In adults, bradypnea is usually defined as fewer than 12 breaths per minute. Bradypnea can be caused by factors such as drug overdose (especially opioids or sedatives), head injury affecting the respiratory center, hypothyroidism, or severe hypothermia. In this scenario, the patient’s respiratory rate is 28 breaths per minute, which is well above the normal adult range of 12–20 breaths per minute. Therefore, bradypnea is incorrect.
B. Tachycardia refers to an elevated heart rate, generally defined as a heart rate greater than 100 beats per minute in adults. It is important not to confuse heart rate terminology with respiratory rate terminology. Since this scenario only provides information about the patient’s breathing, not heart rate, tachycardia is not applicable.
C. Tachypnea is an abnormally rapid respiratory rate, typically defined as greater than 20 breaths per minute in adults. The patient’s rate of 28 breaths per minute falls clearly into this category. Tachypnea can result from a variety of conditions, including fever, anxiety, pain, hypoxia, pulmonary diseases (like asthma, pneumonia, or pulmonary embolism), metabolic acidosis (e.g., diabetic ketoacidosis), or heart failure. Accurately documenting tachypnea is essential, as it is an early indicator of respiratory distress or systemic illness and can guide further assessment and interventions, such as oxygen therapy, monitoring oxygen saturation, or evaluating for underlying causes.
D. Apnea is the complete absence of respirations. It may occur in conditions such as respiratory arrest, severe sleep apnea, or central nervous system depression. Since the patient is actively breathing at a rate of 28, apnea is clearly incorrect.
Correct Answer is ["2"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 50 mg, Concentration = 25 mg/mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 50 ÷ 25
Step 4: Calculate
= 2 mL
Final Answer: 2
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