A nurse is caring for a patient who is postoperative and receiving fentanyl via patient-controlled analgesia. The patient has a prescription for naloxone.
What is the purpose of naloxone?

To suppress respiratory secretions

To block the effects of opioids on the central nervous system

To treat nausea

To treat urinary retention

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.

While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.

It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.

Choice B rationale:

Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).

It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.

This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.

Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.

Choice C rationale:

Naloxone is not effective in treating nausea.

In fact, it can actually worsen nausea in some patients.

This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.

Choice D rationale:

Naloxone is not effective in treating urinary retention.

Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.

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Correct Answer is C

Explanation

Choice A rationale:

A colostomy is a surgical opening in the abdomen that allows stool to pass through the colon and out of the body. While a colostomy may increase the risk of certain complications, such as dehydration and skin irritation, it does not directly increase the risk of aspiration. This is because the colostomy bypasses the upper digestive tract, where aspiration typically occurs.

Choice B rationale:

An ileostomy is a similar surgical opening in the abdomen, but it diverts the small intestine rather than the colon. Like a colostomy, an ileostomy does not directly increase the risk of aspiration. However, it may lead to dehydration and electrolyte imbalances, which could indirectly contribute to aspiration risk.

Choice C rationale:

Enteral feedings through an NG tube are a common way to provide nutrition to patients who cannot eat by mouth. However, these feedings can also increase the risk of aspiration. This is because the NG tube bypasses the normal swallowing mechanisms, which help to protect the airway. If the feeding tube is not properly positioned or if the patient has impaired gastric motility, formula could enter the lungs and cause aspiration pneumonia.

Choice D rationale:

A chest tube is a drainage tube that is inserted into the chest cavity to remove air or fluid. While a chest tube may cause some discomfort and respiratory issues, it does not directly increase the risk of aspiration.

A. Administer theophylline (aminophylline) intravenously for bronchospasms. B. Culture the site of the bee sting and administer antibiotics. C. Provide sips of water to moisten the mouth and throat, which is dry from the tachypnea. D. Administer diphenhydramine (Benadryl), which is an H1 receptor antagonist. E. Prepare for surgical management of the airway.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale:

Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.

Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.

The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.

Choice B rationale:

Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.

Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.

Choice C rationale:

Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.

If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.

Choice D rationale:

Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.

Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.

Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.

Choice E rationale:

Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.

It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.

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A nurse is caring for a patient who is postoperative and receiving fentanyl via patient-controlled analgesia. The patient has a prescription for naloxone. What is the purpose of naloxone?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of patients on an adult medical-surgical unit.Which patient should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

What are the appropriate interventions for a patient experiencing anaphylactic shock from a bee sting? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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A nurse is caring for a patient who is postoperative and receiving fentanyl via patient-controlled analgesia. The patient has a prescription for naloxone.
What is the purpose of naloxone?