The client has taken an overdose of an opioid. The nurse knows the client must be carefully observed for which effect on respirations?

Hyperventilation

Eupnea

Bradypnea

Hyperpnea

Answer and Explanation

The Correct Answer is C

A. Hyperventilation. Opioid overdose depresses the central nervous system, leading to slow and shallow breathing, not increased respiratory rate (hyperventilation).
B. Eupnea. Eupnea refers to normal breathing, which is unlikely in opioid overdose because opioids suppress respiratory drive.
C. Bradypnea. Opioids act on the brainstem's respiratory centers, leading to respiratory depression, characterized by slow breathing (bradypnea) and, in severe cases, respiratory arrest. This is the most life-threatening effect requiring immediate intervention.
D. Hyperpnea. Hyperpnea refers to deep breathing, which is not a typical response to opioid overdose. Instead, breathing becomes slow and shallow, increasing the risk of hypoxia.

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Correct Answer is A

Explanation

A. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. Hypertension is diagnosed based on persistently elevated blood pressure readings across multiple visits, rather than a single elevated measurement.
B. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment. While stress can temporarily elevate blood pressure, a diagnosis should be based on multiple readings rather than withholding information from the patient.
C. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. A cardiology consult is not required to diagnose hypertension; primary care providers can diagnose and manage hypertension independently.
D. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. A reading of 180/100 mmHg indicates hypertensive crisis, but hypertension is diagnosed when blood pressure is consistently ≥140/90 mmHg on multiple occasions.

A. Ask the patient to rate the pain on a 0-to-10 scale. B. Call the physician or health care provider immediately. C. Check the patency of the patient's intravenous line. D. Speak to the patient in a calming tone to reduce anxiety.

Correct Answer is A

Explanation

A. Ask the patient to rate the pain on a 0-to-10 scale. Pain is subjective, and the first step in pain management is assessment. Asking the patient to rate their pain helps determine the severity and whether adjustments to pain management are needed.
B. Call the physician or health care provider immediately. Contacting the provider may be necessary if the pain is uncontrolled, but the nurse must assess the pain level first before deciding if intervention is needed.
C. Check the patency of the patient's intravenous line. While an IV line is essential for PCA function, the priority is assessing the patient’s pain level before troubleshooting the equipment.
D. Speak to the patient in a calming tone to reduce anxiety. Although a calm demeanor is beneficial, it does not address the patient’s pain directly. Pain assessment is the first priority.

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The client has taken an overdose of an opioid. The nurse knows the client must be carefully observed for which effect on respirations?

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Naxlex Comprehensive Predictor Exams

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Explanation

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