A patient is post-op from knee surgery. The patient has been receiving Morphine 4 mg IV every 2 hours. The nurse notices the patient is exhibiting a respiratory rate of 8 and is extremely drowsy. Which of the following conditions is the patient at risk for?
Respiratory acidosis
Hypokalemia
Metabolic acidosis
Respiratory alkalosis
The Correct Answer is A
A. Respiratory acidosis:
This occurs when there is inadequate removal of carbon dioxide (CO2) by the respiratory system. In the case of the patient post-op from knee surgery receiving Morphine, the opioid can cause respiratory depression, leading to the retention of CO2 and the development of respiratory acidosis. Signs include a decreased respiratory rate and drowsiness.
B. Hypokalemia:
This is a condition characterized by low levels of potassium in the blood. While opioids can cause constipation, they are not directly associated with hypokalemia.
C. Metabolic acidosis:
This occurs when there is an increase in acid production or a loss of bicarbonate, leading to an imbalance in the body's acid-base status. The symptoms of metabolic acidosis are not typically associated with opioid use.
D. Respiratory alkalosis:
This occurs when there is excessive elimination of CO2, leading to decreased carbon dioxide levels in the blood. Opioids, especially in higher doses, are more likely to cause respiratory depression and acidosis rather than alkalosis. The patient's low respiratory rate and drowsiness are indicative of respiratory acidosis rather than alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. To prevent post-prandial hypoglycemia:
This statement is not accurate. Insulin Lispro is a rapid-acting insulin used for mealtime coverage to manage post-prandial glucose levels, but it is not given to prevent hypoglycemia.
B. To treat the carbohydrates the client ate:
This statement is more accurate. Insulin Lispro is used to cover the rise in blood sugar that occurs after meals. It helps regulate glucose levels by managing the effect of ingested carbohydrates.
C. To treat the client's blood glucose level:
This statement is generally correct. Insulin Lispro is administered to manage and lower elevated blood glucose levels, especially in response to meals.
D. As a basal dose to prevent hyperglycemia for up to 24 hours:
This statement is incorrect. Insulin Lispro is a rapid-acting insulin and is not used for basal (long-acting) coverage. Basal insulin is usually provided by long-acting insulin formulations.
Correct Answer is B
Explanation
A. Monitoring the patient's breathing and reviewing the patient's arterial blood gases:
Rationale: While respiratory status is crucial in any patient assessment, arterial blood gases primarily evaluate respiratory function. Neutropenia directly affects the immune system, not respiratory function.
Appropriateness: Not directly related to assessing neutropenia.
B. Monitoring the patient's temperature and reviewing the patient's complete blood count with differential:
Rationale: Neutropenia can cause fever due to the increased risk of infection. Monitoring temperature and reviewing the complete blood count (CBC) with differential, specifically the neutrophil count, is essential in evaluating neutropenia and identifying potential infections.
Appropriateness: Correct. Monitoring temperature and reviewing CBC with differential are crucial in assessing neutropenia.
C. Monitoring the patient's blood pressure and reviewing the patient's hematocrit:
Rationale: Blood pressure assessment and hematocrit evaluation are essential aspects of general patient care but are not specific to neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
D. Monitoring the patient's heart rate and reviewing the patient's hemoglobin:
Rationale: Heart rate monitoring and hemoglobin assessment are crucial in various clinical situations but are not specific indicators of neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
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