A nurse is caring for a client who has respiratory depression from an opioid administration.
After administering naloxone to the client, which of the following findings should the nurse expect?
Increased pain.
Somnolence.
Hyperglycemia.
Hypoventilation.
The Correct Answer is A
The correct answer is A. Increased pain.
Choice A reason: Naloxone is an opioid antagonist that, when administered, reverses the effects of opioids. Since opioids provide analgesia, their reversal will lead to the return of pain sensation. The normal pain response varies widely among individuals and depends on the type and amount of opioid the patient received, as well as their pain threshold and tolerance.
Choice B reason: Somnolence, or drowsiness, is a common effect of opioid administration. Naloxone works by displacing opioids from their receptors, which should counteract the sedative effects of opioids and reduce somnolence. Therefore, after naloxone administration, the nurse should not expect somnolence as a finding.
Choice C reason: Hyperglycemia, or high blood sugar, is not a direct effect of naloxone administration. While some studies suggest that naloxone may affect blood glucose levels under certain conditions, such as in the case of tramadol overdose, it does not typically cause hyperglycemia. Normal blood glucose levels range from 70 to 99 mg/dL fasting, and up to 140 mg/dL two hours after eating.
Choice D reason: Hypoventilation, or reduced breathing rate and depth, is caused by opioid administration. Naloxone’s role is to reverse this effect, restoring normal breathing rates. The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is **a. Observe for bruising of the skin.**
Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.
Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.
Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.
Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.
Correct Answer is D
Explanation
The correct answer is D. Contractions.
Choice A Reason: Hypertension Hypertension in pregnancy is a condition that can occur independently of an amniocentesis and is typically monitored throughout the pregnancy. It is characterized by a sustained high blood pressure of 140/90 mmHg or higher. While hypertension is a concern in pregnancy, it is not a direct complication of amniocentesis. Normal ranges for blood pressure in the third trimester are 101.6 to 143.5 mmHg systolic and 62.4 to 94.7 mmHg diastolic.
Choice B Reason: Vomiting Vomiting is not a typical complication following an amniocentesis. It may be associated with other conditions during pregnancy such as hyperemesis gravidarum or gastrointestinal disturbances but is not directly related to the procedure of amniocentesis.
Choice C Reason: Epigastric Pain Epigastric pain is typically associated with conditions like preeclampsia or other gastrointestinal issues in pregnancy, not with amniocentesis. It is characterized by pain in the upper abdomen and is not a common complication post-amniocentesis.
Choice D Reason: Contractions After an amniocentesis, especially at 33 weeks of gestation, monitoring for contractions is crucial because they can indicate preterm labor, which is a known risk associated with the procedure. The normal range for contractions would be none to infrequent Braxton-Hicks contractions, which are not regular and do not signify labor.
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