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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice B reason:While spironolactone can sometimes cause side effects, bruising is not a typical issue associated with this medication.

Choice A reason: Covering your skin before going outside is not an instruction that the nurse should include in this client's plan of care, but rather a general precaution that anyone should take to protect their skin from sun damage. Spironolactone does not increase the risk of sunburn or photosensitivity.

Choice C reason:Spironolactone is a potassium-sparing diuretic that works by blocking aldosterone, which helps reduce fluid retention. However, because it spares potassium, there is a risk of hyperkalemia (high potassium levels). Therefore, clients taking spironolactone should limit their intake of high-potassium foods (e.g., bananas, oranges, spinach, avocados) to avoid dangerous potassium levels.

Choice D reason: Replacing salt with a salt substitute is not an instruction that the nurse should include in this client's plan of care, but rather a dangerous practice that can lead to hyperkalemia. Salt substitutes are often made with potassium chloride, which can increase the potassium level in the blood. The client should use herbs or spices instead of salt or salt substitutes to flavor their food.

A. Hypertension. B. Bradycardia. C. Pupillary constriction. D. Scratchy throat.

Correct Answer is D

Explanation

Choice A reason: Hypertension is not a typical sign of an allergic reaction to piperacillin-tazobactam, which is an antibiotic. It may be caused by other factors, such as pain, anxiety, or renal impairment. The nurse should monitor the client's blood pressure and report any abnormal findings.

Choice B reason: Bradycardia is not a common or serious side effect of piperacillin-tazobactam. It may be related to other medications, such as beta-blockers, or underlying cardiac conditions. The nurse should check the client's pulse and rhythm and report any changes.

Choice C reason: Pupillary constriction is not associated with piperacillin-tazobactam or an allergic reaction. It may be caused by other drugs, such as opioids, or neurological disorders. The nurse should assess the client's level of consciousness and pupillary response.

Choice D reason: Scratchy throat is a possible sign of anaphylaxis, which is a severe and potentially fatal allergic reaction to piperacillin-tazobactam or any other drug. Other symptoms may include hives, swelling, wheezing, or hypotension. The nurse should stop the infusion immediately and call for help.

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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?

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Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client's plan of care?

Correct Answer is C

Explanation

The nurse initiates an infusion of piperacillin-tazobactam for a client with a urinary tract infection. Five minutes into the infusion, the client reports not feeling well. Which client manifestation should the nurse identify as a reason to stop the infusion?

Correct Answer is D

Explanation

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