A nurse is monitoring a client who received naloxone to counteract the effects of an opioid overdose.
Which of the following findings should indicate to the nurse that the medication is effective?

Increased temperature.

Decreased blood pressure.

Increased respiratory rate.

Report of decreased pain.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.

Choice B rationale:

While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.

Choice C rationale:

Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.

Choice D rationale:

Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.

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Correct Answer is C

Explanation

Choice A rationale:

Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.

Choice B rationale:

Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.

Choice C rationale:

Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.

Choice D rationale:

Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.

A. "Using morphine PCA increases the client's risk of toxicity.” B. "Diarrhea is an adverse effect of morphine PCA.” C. "Check the client's pain level every 8 hours.” D. "Instruct the client's visitors not to operate the PCA pump.”

Correct Answer is D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

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A nurse is monitoring a client who received naloxone to counteract the effects of an opioid overdose.Which of the following findings should indicate to the nurse that the medication is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client following his first dose of captopril.The client's blood pressure is 88/60 mm Hg. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is D

Explanation

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A nurse is monitoring a client who received naloxone to counteract the effects of an opioid overdose.
Which of the following findings should indicate to the nurse that the medication is effective?