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: Administering levothyroxine at bedtime is not a correct statement, as it may interfere with sleep quality and hormone absorption. Levothyroxine is a synthetic thyroid hormone that replaces or supplements low levels of natural thyroid hormone in hypothyroidism. Levothyroxine should be taken in the morning, at least 30 minutes before breakfast, to avoid insomnia and ensure optimal absorption.
Choice B reason: Consuming foods that are high in iodine is not a correct statement, as it may affect thyroid function and hormone levels. Iodine is an essential element that is needed for thyroid hormone synthesis. However, too much or too little iodine can cause thyroid disorders, such as goiter or hyperthyroidism. Levothyroxine does not require additional iodine intake, and clients should follow a balanced diet.
Choice C reason: Avoiding the use of iron supplements is a correct statement, but it is not specific to levothyroxine. Iron supplements can interfere with many medications, including levothyroxine, by reducing their absorption and efficacy. Iron supplements should be taken at least 4 hours before or after levothyroxine or other medications.
Choice D reason: Taking medication on an empty stomach is a correct statement that indicates effective education. Levothyroxine should be taken on an empty stomach, preferably in the morning, to avoid food-drug interactions and enhance absorption. Food, especially those high in fiber or calcium, can decrease levothyroxine absorption and effectiveness.
Correct Answer is A
Explanation
Choice A reason: Zolpidem is a hypnotic drug that induces sleep by enhancing the activity of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity. Zolpidem is used to treat insomnia, or difficulty falling asleep or staying asleep. Zolpidem should be taken only at bedtime, when the client is ready to go to sleep and can devote at least seven to eight hours for uninterrupted sleep. Taking zolpidem during the day can cause excessive sedation, drowsiness, confusion, memory loss, and impaired coordination. Therefore, the nurse should encourage the client to wait until bedtime to take the medication and avoid daytime naps.
Choice B reason: Reminding the client to drink plenty of fluids when taking the medication is not an action that the nurse should take in this situation, but rather a general recommendation that applies to most medications. Drinking fluids can help to prevent dehydration, flush out toxins, and maintain kidney function. However, drinking fluids is not specific to zolpidem and does not affect its absorption or metabolism.
Choice C reason: Advising the client to take the medication with the noon meal is not an action that the nurse should take in this situation, but rather a harmful suggestion that can reduce the effectiveness of zolpidem and increase its side effects. Taking zolpidem with food can delay its onset of action and make it less potent. Taking zolpidem at noon can also interfere with the client's circadian rhythm, or natural sleep-wake cycle, and cause daytime sleepiness and nighttime insomnia.
Choice D reason: Explaining that the client needs to allow for sleep time of at least two hours is not an action that the nurse should take in this situation, but rather an inaccurate and insufficient information that can mislead the client and endanger their safety. Zolpidem has a half-life of about two hours, which means that half of its dose is eliminated from the body in two hours. However, this does not mean that its effects wear off in two hours. Zolpidem can still cause residual sedation and impairment for several hours after taking it. The client needs to allow for sleep time of at least seven to eight hours when taking zolpidem, not just two hours.
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