The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?
Prepare to assist with chest tube insertion.
Initiate cardiopulmonary resuscitation (CPR).
Determine Glasgow Coma Scale score.
Administer a second dose of naloxone.
The Correct Answer is D
Choice A reason: Chest tube insertion is not indicated for respiratory depression caused by opioid overdose. It is a procedure used to treat pneumothorax, hemothorax, or pleural effusion.
Choice B reason: CPR is not the first-line intervention for respiratory depression. It is only indicated when the client has no pulse or signs of life.
Choice C reason: Glasgow Coma Scale score is a tool to assess the level of consciousness of a client. It is not an intervention that can reverse respiratory depression.
Choice D reason: Naloxone is an opioid antagonist that can reverse the effects of opioid overdose. It has a short half-life and may need to be repeated if the client's condition does not improve or worsens.
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Related Questions
Correct Answer is C
Explanation
Choice B reason: Naloxone may be necessary, but first, the source of overdose (patches) must be removed to prevent further opioid absorption. After removal, the nurse should assess the severity and then administer naloxone if needed.
Choice A reason: Applying oxygen face mask is not the first action that the nurse should take in this situation, but rather a supportive measure that can be done after administering naloxone. Oxygen can help to improve the client's oxygenation and prevent hypoxia, but it will not reverse the opioid overdose.
Choice C reason: The client is exhibiting signs of opioid overdose, including respiratory depression (shortness of breath) and decreased level of consciousness (difficult to arouse). The first priority is to remove the excess morphine patches to stop further opioid absorption and prevent worsening of the overdose.
Choice D reason: Monitoring blood pressure is not the first action that the nurse should take in this situation, but rather an ongoing assessment that can be done after administering naloxone. Monitoring blood pressure can help to detect any changes in the client's hemodynamic status and guide further interventions, but it will not reverse the opioid overdose.
Correct Answer is ["200"]
Explanation
The correct answer is 200 mL/hr.
Explanation: To calculate the infusion rate, the nurse should use the formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
In this case, the volume is 200 mL and the time is 1 hour. Therefore,
Infusion rate (mL/hr) = 200 mL / 1 hr
Infusion rate (mL/hr) = 200 mL/hr
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