A patient received as-needed morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel (UAP) reports that the patient has a respiratory rate of 10 breaths/min. Which action is priority?
Call the health care provider to obtain a prescription for naloxone
Assess the patient’s responsiveness and respiratory status
Double-check the prescription to see which drugs were prescribed
Obtain a bag-valve mask and deliver breaths at 20 breaths/min
The Correct Answer is B
Choice A reason: Calling the provider for naloxone may be necessary if opioid-induced respiratory depression is confirmed, but the nurse must first assess the patient’s responsiveness and respiratory status. Acting without assessment could delay appropriate intervention or lead to unnecessary treatment.
Choice B reason: Assessing the patient’s responsiveness and respiratory status is the priority. A respiratory rate of 10 breaths/min is low and concerning, especially after receiving sedatives, opioids, and muscle relaxants. The nurse must determine the patient’s level of consciousness, oxygen saturation, and quality of respirations before deciding on further interventions. This ensures that the response is tailored to the patient’s actual condition.
Choice C reason: Double-checking prescriptions is part of safe medication practice, but it is not the immediate priority in this situation. The patient’s current clinical status must be assessed first to prevent deterioration.
Choice D reason: Obtaining a bag-valve mask and delivering breaths at 20 breaths/min is a resuscitative measure reserved for patients who are unresponsive or in severe respiratory failure. Since the patient’s condition has not yet been fully assessed, this action would be premature. It may be required later if the patient is found to be unresponsive, but assessment must come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Asking one Question at a time reduces cognitive load for a client with late-stage dementia. These clients often have impaired short-term memory and difficulty processing complex information. By limiting communication to one Question , the nurse ensures clarity and prevents confusion, which enhances the likelihood of an appropriate response.
Choice B reason: Frequently redirecting to reality is not effective in late-stage dementia. At this stage, clients often experience profound memory loss and disorientation that cannot be corrected by reality orientation. Attempting to redirect them can increase agitation and frustration. Instead, validation therapy or focusing on comfort is more appropriate.
Choice C reason: Giving one instruction at a time is essential because dementia impairs executive functioning and the ability to follow multi-step directions. Breaking tasks into single, simple instructions allows the client to process and complete them successfully, reducing anxiety and promoting cooperation.
Choice D reason: Positioning yourself at eye level with the client promotes dignity, respect, and effective communication. Eye-level positioning reduces intimidation, fosters trust, and helps the client focus on facial cues and lip movements, which are critical when verbal comprehension is impaired.
Choice E reason: Allowing time for the client to respond is crucial because dementia slows cognitive processing. Clients may need extended time to interpret the Question and formulate a response. Rushing them can cause frustration and withdrawal, while patience supports engagement and reduces stress.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: New onset of respiratory stridor indicates acute upper airway obstruction. Stridor is a high-pitched sound caused by turbulent airflow through a narrowed airway. This is a medical emergency because airway compromise can rapidly progress to respiratory failure. Immediate intervention is required to secure the airway and prevent hypoxia.
Choice B reason: Shortness of breath persisting for 20 minutes suggests significant respiratory distress. Prolonged dyspnea indicates impaired oxygenation or ventilation, which can quickly deteriorate if not addressed. This symptom requires immediate nursing action to assess oxygen saturation, provide supplemental oxygen, and notify the provider.
Choice C reason: A blood pressure of 150/84 is mildly elevated but not immediately life-threatening. Hypertension at this level does not require urgent intervention in the absence of other critical symptoms. It should be monitored and managed, but it does not demand immediate action compared to airway or severe acid-base disturbances.
Choice D reason: Nervousness associated with anxiety is not an urgent clinical finding. While anxiety can affect patient comfort and may exacerbate symptoms, it does not represent a life-threatening condition requiring immediate intervention. Supportive measures can be provided after stabilizing critical issues.
Choice E reason: ABG results showing pH 7.12, PaCO2 28 mmHg, and PaO2 55 mmHg indicate severe metabolic acidosis with hypoxemia. A pH of 7.12 reflects life-threatening acidemia, while PaO2 of 55 mmHg shows inadequate oxygenation. This combination requires immediate intervention to correct oxygenation and acid-base balance, as it can lead to cardiovascular collapse and multi-organ dysfunction if untreated.
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