A nurse is teaching a newly licensed nurse about assessing a client who received naloxone to treat opioid toxicity. The nurse should include that which of the following findings indicate the intervention is effective?
Cheyne-stokes respirations
Substernal retractions during respirations
Increased respirations
Kussmaul respirations
The Correct Answer is C
Naloxone is an opioid antagonist used to rapidly reverse the effects of an opioid overdose, which often includes severely slowed or stopped breathing.
- CheyneStokes respirations (A) and Kussmaul respirations (D) are abnormal breathing patterns that are not indicative of effective naloxone treatment.
- Substernal retractions (B) indicate difficulty breathing, which would not suggest that the naloxone has been effective.
- Effective naloxone intervention is typically indicated by the restoration of normal breathing patterns in a person who has experienced opioid toxicity.
A-Cheyne stokes respirations is due to conditions such as stroke, brain injury
B-Substernal retraction occur in respiratory distress due to pulmonary conditions such as pneumonia D-Kussmaul breathing is found in diabetes ketoacidosis
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale- metabolic acidosis, a nurse would expect to find an arterial blood gas (ABG) result showing a pH below 7.35, indicating an acidic state. Metabolic acidosis is characterized by a decrease in bicarbonate (HCO₃), so an HCO₃ level above 26 mEq/L would not be typical for this condition. Instead, a value below the normal range (22-26 mEq/L) would be expected. PaCO₂ levels above 45 mm Hg would suggest respiratory acidosis, not metabolic acidosis.
Correct Answer is D
Explanation
High doses of acetaminophen can lead to liver injury. Liver injury prevents the metabolism and absorption of bilirubin in the liver parenchyma. This leads to increased levels of unconjugated bilirubin in the blood that presents with jaundice.
A-Hyperglycemia is not an adverse effect of acetaminophen
B-Tinnitus is an adverse effects of salicylates
C-Muscle pain is not an adverse effect of acetaminophen
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