A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?
Diaphoresis
Pupillary dilation
Chest pain
Hypotension
The Correct Answer is D
Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.
Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.
Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .
Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
Correct Answer is C
Explanation
The correct answer is choice C, weigh the client before and after the treatment. The nurse should weigh the client before and after the treatment to evaluate the effectiveness of the dialysis, and determine whether the appropriate amount of fluid has been removed. Choice A is incorrect because the dialysate should be warmed prior to infusion, not chilled. Choice B is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags. Choice D is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Choice A: Chilling the dialysate prior to infusion is incorrect because the dialysate should be warmed prior to infusion, not chilled.
Choice B: Using clean gloves when handling dialysate bags is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags.
Choice D: Monitoring the client for diarrhea is incorrect because diarrhea is not a common complication of peritoneal dialysis.
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