The nurse administers naloxone to a patient with opioid-induced respiratory depression.
An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive.
What action should the nurse take?

Administer a second dose of naloxone.

Prepare to assist with chest tube insertion.

Determine Glasgow Coma Scale score.

Initiate cardiopulmonary resuscitation (CPR). .

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: Initiate cardiopulmonary resuscitation (CPR).

Choice D rationale: The patient's respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression, which requires immediate intervention. CPR is the priority action to maintain circulation and oxygenation while awaiting further interventions.

Choice A rationale: Administering a second dose of naloxone may be necessary to counteract the effects of opioids. However, in this case, the patient's condition has severely deteriorated, and immediate resuscitation efforts take priority.

Choice B rationale: Preparing to assist with chest tube insertion is not the appropriate action in this situation. Chest tube insertion is used to treat conditions like pneumothorax or pleural effusion, which are not indicated in this scenario.

Choice C rationale: Determining the Glasgow Coma Scale score is useful for assessing the patient's level of consciousness but should not be the first action in this case. Ensuring adequate circulation and oxygenation through CPR is the priority.

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Correct Answer is A

Explanation

Choice A rationale

Tamsulosin is an alpha-blocker that relaxes the smooth muscles of the prostate and bladder neck, improving urine flow. However, it can also cause hypotension, dizziness, and fainting as adverse effects. Therefore, monitoring blood pressure is essential for clients taking tamsulosin.

Choice B rationale

While assessing the client’s urine output is an important part of monitoring a client with benign prostatic hyperplasia, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice C rationale

Performing a bladder scan can be useful in assessing the client’s urinary retention, a common symptom of benign prostatic hyperplasia. However, it is not specifically related to monitoring for adverse reactions to tamsulosin.

Choice D rationale

Obtaining the client’s daily weights can be useful in monitoring fluid balance, but it is not specifically related to monitoring for adverse reactions to tamsulosin.

A. Withhold the scheduled dose and notify the healthcare provider. B. Administer the dose and monitor the client’s BP regularly. C. Assess for orthostatic hypotension before administering the dose. D. Apply a telemetry monitor before administering the dose.

Correct Answer is A

Explanation

Choice A rationale

Labetalol is a non-selective beta-blocker used to treat hypertension. The goal of labetalol administration is to reduce the blood pressure to 140/90 mmHg, and the diastolic BP must not fall below 90 mmHg. However, in this scenario, the client’s heart rate is 48 beats/minute, which is lower than the normal range (60-100 beats/minute). Administering labetalol, which can further decrease heart rate, could lead to bradycardia, a condition that can cause fainting, fatigue, or chest discomfort. Therefore, the nurse should withhold the scheduled dose and notify the healthcare provider.

Choice B rationale

While it is important to monitor the client’s BP regularly when administering labetalol, given the client’s low heart rate, administering the dose could potentially exacerbate the client’s bradycardia. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice C rationale

Assessing for orthostatic hypotension before administering the dose is an important consideration when administering medications that can lower blood pressure. However, in this case, the client’s low heart rate is a more immediate concern. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice D rationale

Applying a telemetry monitor could help in monitoring the client’s heart rate and rhythm. However, given the client’s current heart rate, the priority should be to withhold the medication and inform the healthcare provider.

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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with benign prostatic hyperplasia has been prescribed tamsulosin. What should the nurse do to monitor for an adverse reaction?

Correct Answer is A

Explanation

The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

Correct Answer is A

Explanation

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The nurse administers naloxone to a patient with opioid-induced respiratory depression.
An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive.
What action should the nurse take?