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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU).

Exhibits

A nurse has assessed the postoperative client. Which of the following interventions are needed immediately?
(Select All that Apply.)

Give naloxone 0.2 mg IV STAT

Bag-valve-mask (BVM) ventilations

Chest compressions

Defibrillation

Incentive spirometry

Chest physiotherapy (CPT)

Give 2 units of packed red blood cells (PRBCs)

Obtain crash cart

Correct electrolyte imbalance(s)

Give morphine sulfate 2 mg IV x 1 STAT

Answer and Explanation

Correct Answer : A,B,H

A. Give naloxone 0.2 mg IV STAT
The client has received multiple opioids (fentanyl + morphine) and is now increasingly somnolent, minimally responsive, with shallow respirations and low oxygen saturation. These are classic signs of opioid-induced respiratory depression, and naloxone (an opioid antagonist) should be administered immediately.

B. Bag-valve-mask (BVM) ventilations
The client has shallow respirations and poor oxygenation (SpO₂ dropped to 92%) and is minimally responsive. BVM is essential to maintain oxygenation and ventilation while naloxone takes effect or if apnea develops.

C. Chest compressions
There is no indication of cardiac arrest. The client still has a pulse and blood pressure, though hypotensive.

D. Defibrillation
There is no mention of a shockable rhythm (e.g., V-fib or pulseless V-tach). Defibrillation is not indicated for respiratory depression or somnolence.

E. Incentive spirometry
The client is minimally responsive and unable to cooperate with incentive spirometry. This is used post-op for alert clients to prevent atelectasis, not for unconscious or sedated patients.

F. Chest physiotherapy (CPT)
Not appropriate for this case. CPT is used for mucus clearance in conditions like COPD or pneumonia, not for opioid-induced respiratory depression.

G. Give 2 units of packed red blood cells (PRBCs)
There is no sign of active bleeding or anemia. Hemoglobin was not reported to be low, and there are no signs of hemorrhagic shock.

H. Obtain crash cart
The client is decompensating rapidly - lethargy, hypotension, and respiratory depression could progress to respiratory or cardiac arrest. Having the crash cart ready ensures that resuscitation medications and defibrillation (if needed) are available without delay.

I. Correct electrolyte imbalance(s)
There is no data provided suggesting an electrolyte imbalance. This is not a priority in the setting of opioid overdose with respiratory compromise.

J. Give morphine sulfate 2 mg IV x 1 STAT
This would worsen the client’s condition by increasing opioid load in someone already experiencing opioid toxicity. It’s absolutely contraindicated.

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Correct Answer is B

Explanation

A. Collect urine specimen
Appropriate to assess for hemoglobinuria during a hemolytic reaction.

B. Starts another unit of blood
Incorrect action—transfusion must be stopped and not restarted without provider evaluation.

C. Initiates 0.9% sodium chloride infusion
Maintains vascular access and supports renal perfusion-appropriate.

D. Sends blood specimen
Required for follow-up testing and identification of reaction cause.

Correct Answer is ["5"]

Explanation

Calculation:
5 mg ÷ 1 mg/mL = 5 mL

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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU). Exhibits A nurse has assessed the postoperative client. Which of the following interventions are needed immediately? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

Correct Answer is B

Explanation

A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol injection 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["5"]

Explanation

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A nurse is caring for a post-operative client in the post anesthesia care unit (PACU).

Exhibits

A nurse has assessed the postoperative client. Which of the following interventions are needed immediately?
(Select All that Apply.)