A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.

Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.

Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.

Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.

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Correct Answer is A

Explanation

Choice A reason: Guided meditation and other nonpharmacological pain interventions can help reduce the perception of pain, which may allow for lower doses of pain management medications. This is beneficial as it can reduce the risk of side effects and dependency associated with higher doses of pain medications1. Studies have shown that integrating nonpharmacological methods like guided meditation can enhance overall pain management and improve the quality of life for patients2.

Choice B reason: Guided meditation is a complementary therapy and is not intended to replace pain medications entirely. While it can significantly aid in pain management, it is typically used alongside pharmacological treatments to provide a holistic approach to pain relief3. Relying solely on guided meditation without appropriate medical supervision and medication can lead to inadequate pain control.

Choice C reason: Guided meditation is not limited to hospital settings or licensed therapists. Many guided meditation resources are available online, through apps, or in community centers, making it accessible to a broader audience4. Patients can practice guided meditation at home, which provides flexibility and convenience in managing chronic pain.

Choice D reason: Pain medications are often prescribed on a regular schedule to maintain consistent pain control, especially in chronic pain conditions. While nonpharmacological interventions can reduce the need for frequent dosing, they do not eliminate the necessity for scheduled pain medications5. It is essential to follow a healthcare provider’s recommendations for medication administration to ensure effective pain management.

A. A nurse is educating a client about supplements that are effective for nausea. Which supplement should the nurse include? B. Ask the client to clench their teeth. C. Ask the client to read a Snellen chart. D. Ask the client to raise his eyebrows.

Correct Answer is B

Explanation

Choice A Reason:

Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.

Choice B Reason:

Clenching the teeth is a method used to assess the motor function of cranial nerve V (the trigeminal nerve). The trigeminal nerve is responsible for the movement of the muscles involved in chewing. When a client clenches their teeth, the nurse can palpate the masseter and temporal muscles to check for strength and symmetry. This helps determine if there are any abnormalities in the motor function of the trigeminal nerve.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V.

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

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A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is recommending guided meditation as a nonpharmacological pain intervention for a client experiencing chronic pain. What information should the nurse include when teaching the client about nonpharmacological pain interventions?

Correct Answer is A

Explanation

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Correct Answer is B

Explanation

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:

A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

A primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?