A recent postoperative client is being transferred back to the medical-surgical unit. The client is receiving morphine through a patient-controlled analgesia (PCA) pump. The nurse notes that the client is lethargic, with a blood pressure of 118/66 and respirations of 8. What should the nurse have readily available?

Oxygen and suction equipment

Naloxone

IV fluids

Blood pressure monitor

Answer and Explanation

The Correct Answer is B

Choice A reason: Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.

Choice B reason: Naloxone, an opioid antagonist, reverses morphine-induced respiratory depression and lethargy. A respiratory rate of 8 breaths/min signals overdose, risking hypoxia and brain damage. Naloxone restores normal respiration by blocking opioid receptors, making it critical to have readily available for immediate administration in this scenario.

Choice C reason: IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.

Choice D reason: A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.

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Correct Answer is C

Explanation

Choice A reason: Notifying the provider delays airway restoration in a tracheostomy dislodgement. The priority is maintaining the airway, as the stoma may close rapidly in a chronic tracheostomy, risking respiratory distress, making immediate tube reinsertion critical over notification.

Choice B reason: Ventilating with a bag-valve-mask provides temporary oxygenation but does not address the dislodged tracheostomy tube. In a chronic tracheostomy, the stoma is the primary airway, and reinserting the tube prevents closure, making ventilation a secondary action.

Choice C reason: Attempting to reinsert a new tracheostomy tube is the priority, as chronic tracheostomy stomas may close rapidly, risking airway loss. Prompt reinsertion maintains patency, preventing respiratory distress or emergent surgical intervention, making this critical for client safety and breathing.

Choice D reason: Covering the stoma with an occlusive dressing risks airway obstruction in a chronic tracheostomy, where the stoma is the primary airway. This could lead to respiratory distress, as the client depends on the tracheostomy, making this incorrect compared to tube reinsertion.

A. Dilated and reactive pupils B. Decreased respiratory rate C. Urine output of 50 mL/hr D. Heart rate of 100 beats/minute

Correct Answer is B

Explanation

Choice A reason: Dilated and reactive pupils are unrelated to albuterol’s effect. Albuterol, a bronchodilator, relaxes bronchial smooth muscles to improve airflow in emphysema. Pupil changes may indicate neurological or systemic issues but are not a direct indicator of albuterol’s effectiveness in relieving bronchoconstriction and respiratory distress.

Choice B reason: Decreased respiratory rate indicates albuterol’s therapeutic effect in emphysema. Albuterol relaxes constricted airways, improving airflow and reducing the work of breathing. This leads to a slower, more effective respiratory rate, reflecting better oxygenation and relief of bronchospasm, making it the primary sign of therapeutic success.

Choice C reason: Urine output of 50 mL/hr is normal but unrelated to albuterol’s effect. Albuterol targets bronchial smooth muscles to relieve bronchoconstriction in emphysema, improving respiratory function. Urine output reflects renal function, not airway improvement, making it an irrelevant indicator of albuterol’s therapeutic effectiveness in this context.

Choice D reason: A heart rate of 100 beats/minute may occur as a side effect of albuterol’s beta-adrenergic stimulation but is not the primary therapeutic indicator. Albuterol aims to improve airflow and reduce respiratory distress, evidenced by a decreased respiratory rate, not tachycardia, which is a secondary effect.

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Naxlex Comprehensive Predictor Exams

The nurse is providing tracheostomy care for a client with a chronic tracheostomy, and the tube falls out. What priority action should the nurse initiate?

Correct Answer is C

Explanation

A nurse administers albuterol as ordered to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Correct Answer is B

Explanation

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) and auscultates moist, rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

A nurse is caring for a client with bacterial pneumonia and has received an order for antibiotics. Which diagnostic test must be ordered before initiating antibiotic therapy to ensure appropriate treatment?

The nurse is caring for a client with a chest tube. Which supplies should the nurse ensure are readily available at the client's bedside for emergencies?

The nurse is caring for a client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?

A stable postoperative client is ready to leave the post-anesthesia care unit (PACU). Which nursing action is most important by the nurse on the medical-surgical unit?

The unlicensed assistive personnel (UAP) notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 20, pulse 122, and BP 98/72. Which actions should the nurse do next?