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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Recent use of other antidepressants is important to know, as duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that can interact with other antidepressants, especially monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs). However, this information is not as important as liver function laboratory results, as duloxetine can cause hepatotoxicity in some clients.
Choice B reason: Weight change in the last month is relevant to monitor, as duloxetine can cause weight loss or gain in some clients. However, this information is not as important as liver function laboratory results, as duloxetine can cause liver damage in some clients.
Choice C reason: Family history of mental illness is useful to assess, as duloxetine may be more effective or less effective in clients with certain genetic factors. However, this information is not as important as liver function laboratory results, as duloxetine can cause liver failure in some clients.
Choice D reason: Liver function laboratory results are most important to obtain, as duloxetine is metabolized by the liver and can cause hepatotoxicity in some clients. The nurse should monitor the client's liver enzymes and bilirubin levels before and during treatment with duloxetine and report any signs of liver impairment, such as jaundice, dark urine, abdominal pain, or fatigue.
Correct Answer is A
Explanation
Choice A reason: Ferrous sulfate is best absorbed on an empty stomach, so waiting 2 hours after meals to take the tablet will enhance its effectiveness. Food can interfere with iron absorption, especially dairy products, eggs, coffee, tea, and antacids.
Choice B reason: Bedtime is not the best time to take the tablet, because lying down after taking iron can cause gastrointestinal upset, such as nausea, vomiting, constipation, or diarrhea. The client should take the tablet with a full glass of water and remain upright for at least 30 minutes.
Choice C reason: Taking the tablet with a daily multivitamin is not recommended, because some vitamins and minerals can reduce iron absorption, such as calcium, zinc, copper, and vitamin E. The client should avoid taking iron with other supplements unless advised by the healthcare provider.
Choice D reason: Crushing the tablets and mixing with pudding is not advisable, because enteric-coated tablets are designed to dissolve slowly in the intestine and protect the stomach from irritation. Crushing them will destroy their coating and reduce their effectiveness. The client should swallow the tablets whole and not chew or crush them.
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