Exhibits

Which should the nurse do immediately? Select all that apply.

Provide rescue breaths with a manual ventilation bag

Print an electrocardiogram strip

Call for rapid response

Give naloxone 2 mg intravenous push

Perform chest compressions

Apply oxygen via nasal cannula

Answer and Explanation

Correct Answer : A,C,D

A. Provide rescue breaths with a manual ventilation bag: The client’s respiratory rate is dangerously low (5 breaths/min), and oxygen saturation is critically low (54%), indicating respiratory failure. Immediate manual ventilation supports breathing and oxygenation until further interventions take effect.

B. Print an electrocardiogram strip: While cardiac monitoring is important, printing an ECG strip is not the immediate priority in a client with severe respiratory depression and hypoxia. Life-saving respiratory interventions take precedence.

C. Call for rapid response: The client’s altered mental status, respiratory depression, and hypoxia constitute a medical emergency. Activating the rapid response team ensures prompt multidisciplinary intervention.

D. Give naloxone 2 mg intravenous push: Naloxone is an opioid antagonist and is essential to reverse morphine-induced respiratory depression. Administering naloxone promptly can restore respiratory function.

E. Perform chest compressions: The client has a pulse (heart rate 92 beats/minute), so chest compressions are not indicated at this time. CPR is reserved for pulselessness or severe cardiac arrest.

F. Apply oxygen via nasal cannula: Applying oxygen via a nasal cannula is insufficient for a client with a respiratory rate of 5 breaths/minute and an oxygen saturation of 54%. This client needs immediate ventilatory support and a higher concentration of oxygen

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Correct Answer is C

Explanation

A. Take medication with meals: Taking baclofen with meals helps minimize gastrointestinal side effects such as nausea and upset stomach. This instruction supports better medication tolerance and adherence.

B. Use a stool softener as needed: Baclofen can cause constipation due to its muscle-relaxant effects on smooth muscles, so using a stool softener as needed helps prevent or relieve constipation and promotes comfort.

C. Discontinue when spasms cease: Baclofen should not be stopped abruptly because sudden discontinuation can cause serious withdrawal symptoms such as increased spasticity, hallucinations, or seizures. Tapering the dose gradually under medical supervision is essential to avoid adverse effects.

D. Avoid the ingestion of alcohol: Alcohol can increase the sedative effects of baclofen, leading to excessive drowsiness, dizziness, or impaired coordination, which can increase the risk of falls or accidents. Avoiding alcohol is important for safety.

A. Administer levothyroxine at bed time. B. Take medication on an empty stomach. C. Avoid the use of iron supplements. D. Consume foods that are high in iodine.

Correct Answer is B

Explanation

A. Administer levothyroxine at bed time: Levothyroxine is best taken in the morning to mimic the body’s natural hormone rhythm and to avoid interference from food, so taking it at bedtime is not standard unless specifically directed by the provider.

B. Take medication on an empty stomach: Levothyroxine absorption is optimal when taken on an empty stomach, ideally 30–60 minutes before breakfast, to avoid binding with food or other medications.

C. Avoid the use of iron supplements: Iron can interfere with levothyroxine absorption, but it can be taken if spaced at least 4 hours apart. Avoidance is not required, only timing adjustments.

D. Consume foods that are high in iodine: Excess iodine can actually disrupt thyroid function and is not recommended unless prescribed for a specific deficiency.

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Exhibits Which should the nurse do immediately? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is C

Explanation

A client receives a new prescription for levothyroxine. Which statement made by the client indicates to the nurse that education was effective?

Correct Answer is B

Explanation

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The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the effectiveness of the medication?

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Exhibits

Which should the nurse do immediately? Select all that apply.