Patient Data

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

Print an electrocardiogram strip

Call for rapid response

Perform chest compressions

Apply oxygen via nasal cannula

Give naloxone 2 mg intravenous push

Provide rescue breaths with a manual ventilation bag

Answer and Explanation

Correct Answer : B,E,F

A. Print an electrocardiogram strip: While cardiac monitoring is important, printing an ECG strip does not immediately address the critical issue of respiratory depression and unresponsiveness. Priority actions must focus on airway and breathing first.

B. Call for rapid response: The client is critically unstable with severe respiratory depression and unresponsiveness, meeting criteria for a rapid response or even a code blue if the situation deteriorates further. Immediate expert team support is crucial.

C. Perform chest compressions: Chest compressions are only indicated if the client is pulseless. In this case, the client has a heart rate of 92 beats/minute, meaning compressions are not appropriate at this moment.

D. Apply oxygen via nasal cannula: A nasal cannula would not deliver high enough oxygen concentrations for someone with a respiratory rate of 5 breaths/minute and oxygen saturation of 54%. Higher oxygen delivery methods and ventilatory support are urgently needed.

E. Give naloxone 2 mg intravenous push: Naloxone is indicated immediately to reverse opioid-induced respiratory depression. Giving the prescribed naloxone IV push can rapidly counteract the morphine overdose and improve the client’s respiratory effort.

F. Provide rescue breaths with a manual ventilation bag: Because the client’s respirations are critically low, rescue breathing with a manual resuscitation bag is necessary to maintain oxygenation and ventilation until naloxone takes effect or more advanced airway management is available.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Verify that the urine output exceeds 30 mL per hour: Although adequate urine output is important for assessing overall kidney function, it is not directly related to the safe administration of digoxin. Digoxin administration is primarily concerned with heart rate and rhythm, not renal perfusion measures before dosing.

B. Check the client for signs of orthostatic hypotension: Orthostatic hypotension assessment is valuable in many clinical scenarios but is not the primary safety check required before administering digoxin. The priority is to ensure the heart rate is sufficient and regular, as digoxin can cause bradycardia.

C. Listen to the heart at the left 5th intercostal space: Digoxin can cause significant bradycardia and arrhythmias. Therefore, the nurse must auscultate the apical heart rate at the 5th intercostal space at the midclavicular line for a full minute to determine if the rate is within safe limits for administration, 60 – 100 beats per minute in adults.

D. Obtain a left radial pulse rate for a full 30 seconds: Checking a peripheral pulse for only 30 seconds is inadequate for evaluating the cardiac effects of digoxin. Peripheral pulses may be irregular or faint in cases of dysrhythmias, leading to inaccurate assessment compared to direct apical heart auscultation.

A. Take the medication during pregnancy. B. Use folic acid to protect the liver. C. Store the medication at room temperature. D. Obtain a platelet count weekly.

Correct Answer is A

Explanation

A. Take the medication during pregnancy: Methotrexate is highly teratogenic and absolutely contraindicated during pregnancy because it can cause severe fetal malformations or death. Clients must be instructed to avoid pregnancy while on methotrexate and for some time after discontinuing the drug, making this a critical point requiring immediate correction.

B. Use folic acid to protect the liver: Methotrexate interferes with folate metabolism, and folic acid supplementation is recommended to reduce some side effects such as liver toxicity, mucositis, and bone marrow suppression. This statement reflects appropriate understanding of supportive care during methotrexate therapy.

C. Store the medication at room temperature: Methotrexate should be stored at room temperature away from light and moisture, consistent with safe medication handling practices. This information is accurate and does not require additional instruction.

D. Obtain a platelet count weekly: Methotrexate can cause bone marrow suppression, increasing the risk of thrombocytopenia. Regular monitoring of blood counts, including platelets, is standard practice to detect toxicity early, so this action is appropriate and understood correctly.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

Correct Answer is C

Explanation

A client receives a prescription for methotrexate. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is A

Explanation

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Patient Data

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