A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
The initial administration of the analgesic.
The decision regarding when to call the healthcare provider.
The documentation of the client's respiratory rate.
The administration of naloxone via IV.
The Correct Answer is B
Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.
Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's
respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.
Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.
Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This intervention is not the best because it may take too much time and energy from the nurse, who needs to focus on the client's critical condition. The nurse may also have to repeat the same information multiple times, which can be frustrating and confusing for both the nurse and the family.
B) This intervention is not the best because it may not be feasible or appropriate at this time. The healthcare provider may be busy with other clients or procedures, and may not be able to speak with the family right away. The healthcare provider may also need to obtain the client's consent or permission before disclosing any information to the family, which may not be possible if the client is sedated.
C) This intervention is the best because it can help reduce the number and frequency of questions, and facilitate clear and consistent communication between the nurse and the family. The nurse can ask the family to choose one person who will act as their representative and spokesperson, and who will relay any information or updates to the rest of the family. This can also help respect the client's privacy and confidentiality, and prevent any conflicting or contradictory messages.
D) This intervention is not the best because it may not address the family's informational needs or preferences. The chaplain on call may provide spiritual or emotional support to the family, but may not be able to answer any medical or technical questions. The family may also have different religious or cultural beliefs that may not align with the chaplain's role or perspective.
Correct Answer is B
Explanation
Choice A Reason: The ability to update the equipment each year may be desirable, but not the most important question to consider. Updating the equipment may incur additional costs and may not be necessary or feasible depending on the type and function of the equipment.
Choice B Reason: The number of departments that can use the equipment is the most important question to
consider, as it reflects the potential impact and benefit of the equipment for the organization. The more departments that can use the equipment, the more efficient and cost-effective it will be.
Choice C Reason: The cost of equipment is an important question to consider, but not the most important one. The cost of equipment should be compared with the expected benefits and outcomes of using the equipment, not just in terms of monetary value, but also in terms of quality of care and patient satisfaction.
Choice D Reason: The need for annual repair is an important question to consider, but not the most important one. The need for annual repair may indicate the reliability and durability of the equipment, but it may also depend on the frequency and intensity of use, and the availability and accessibility of maintenance services.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today