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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Correct Answer is A

Explanation

A. Dry mouth, blurred vision, and constipation: These symptoms are classic anticholinergic side effects associated with many antidepressants, especially tricyclic antidepressants (TCAs). They result from the blockade of muscarinic receptors and are frequently reported by clients receiving these medications.

B. Headache, jaundice, and diarrhea: While headaches can occur with antidepressant use, jaundice is rare and would suggest serious liver toxicity rather than a common side effect. Diarrhea may happen with selective serotonin reuptake inhibitors (SSRIs) but is less typical overall than anticholinergic symptoms.

C. Bradycardia, delirium, and sedation: Some antidepressants can cause sedation, but bradycardia and delirium are not common side effects across the entire antidepressant class. These would be more likely associated with toxicity or drug interactions rather than typical daily use.

D. Insomnia, hypertension, and vomiting: Insomnia can occur with certain antidepressants like SSRIs or SNRIs, but hypertension and vomiting are less consistently seen across all antidepressant classes. These symptoms are not considered the hallmark side effects of antidepressant therapy.

A. Have a manual resuscitation bag at the bedside. B. Suction the client to clear the airway. C. Ask the client about other medications she takes. D. Perform a 12-lead electrocardiogram. E. Restrain the client with soft restraints. F. Take an initial respiratory rate.

Correct Answer is ["A","C","F"]

Explanation

A. Have a manual resuscitation bag at the bedside: Because morphine can cause respiratory depression, it is critical to have emergency resuscitation equipment readily available in case the client requires assisted ventilation during an adverse reaction.

B. Suction the client to clear the airway: Routine suctioning is not necessary unless the client has secretions impairing airway patency. It is not a standard precaution for clients receiving IV morphine without signs of airway obstruction.

C. Ask the client about other medications she takes: Morphine can interact dangerously with other medications, particularly sedatives, benzodiazepines, and other central nervous system depressants. Knowing the client’s full medication list helps prevent additive respiratory depression.

D. Perform a 12-lead electrocardiogram: A 12-lead ECG is not a standard requirement when starting morphine therapy unless there are cardiac symptoms. Continuous cardiorespiratory monitoring is already ordered, and that level of cardiac surveillance is sufficient unless new cardiac concerns arise.

E. Restrain the client with soft restraints: Restraints are not appropriate unless the client becomes a danger to herself or others. Administering morphine does not justify the prophylactic use of restraints and would violate ethical care standards.

F. Take an initial respiratory rate: An initial baseline respiratory rate is critical before starting or continuing morphine, as the drug’s main risk is respiratory depression. Ongoing respiratory assessments will be essential during PCA therapy.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","C","F"]

Explanation

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Patient Data

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