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). .

None

Answer and Explanation

The Correct Answer is A

The patient’s respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression and a life-threatening emergency. Naloxone was administered an hour ago, but its effects typically last 30–90 minutes, and opioid effects may outlast it, especially with long-acting opioids. The priority is to address the immediate threat to life.

A. Administer a second dose of naloxone: Naloxone reverses opioid-induced respiratory depression. Given the recurrence of severe symptoms, a repeat dose is appropriate to counteract potential ongoing opioid effects.
B. Prepare to assist with chest tube insertion: This is irrelevant, as there’s no indication of pneumothorax or other conditions requiring a chest tube.
C. Determine Glasgow Coma Scale score: While assessing neurological status is useful, it’s not the priority when the patient is in acute respiratory failure.
D. Initiate cardiopulmonary resuscitation (CPR): CPR is indicated for cardiac arrest, but the patient has a respiratory rate (albeit critically low) and no mention of absent pulse, so CPR is not yet warranted.

The most appropriate action is to administer a second dose of naloxone to reverse the opioid-induced respiratory depression, followed by close monitoring and supportive care (e.g., oxygen, ventilation support if needed).

Final Answer: A. Administer a second dose of naloxone.

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Correct Answer is B

Explanation

Choice A rationale

Glucagon should not be administered before meals to prevent hyperglycemia. Glucagon is a hormone that raises blood glucose levels and is used to treat severe hypoglycemia. It is not intended to prevent hyperglycemia.

Choice B rationale

Glucagon should be administered when signs of severe hypoglycemia occur. Hypoglycemia, or low blood sugar, can cause symptoms such as confusion, dizziness, hunger, and shakiness. If left untreated, severe hypoglycemia can lead to unconsciousness or seizures.

Choice C rationale

Glucagon should not be administered when unable to eat during sick days. While it’s important to maintain blood glucose levels during illness, glucagon is specifically used for severe hypoglycemia.

Choice D rationale

Glucagon should not be administered at the onset of signs of diabetic ketoacidosis. Diabetic ketoacidosis is a serious condition that requires immediate medical attention. Glucagon is not a treatment for this condition.

A. Inform the patient that the medication has been effective. B. Review the patient’s culture and sensitivity reports. C. Implement neutropenic precautions. D. Assess the patient’s vital signs.

Correct Answer is A

Explanation

Choice A rationale

Filgrastim is a medication used to stimulate the growth of white blood cells, making patients less vulnerable to infections. If the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3 after administering five doses of filgrastim, it indicates that the medication has been effective.

Choice B rationale

Reviewing the patient’s culture and sensitivity reports is not directly related to the effect of filgrastim on white blood cell count.

Choice C rationale

Neutropenic precautions are typically implemented when a patient has a low white blood cell count. Since the patient’s white blood cell count has increased, implementing neutropenic precautions may not be necessary.

Choice D rationale

While it’s always important to monitor a patient’s vital signs, there’s no specific reason to do so just because the patient’s white blood cell count has increased after administering filgrastim.

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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 patient with type 1 diabetes mellitus has been prescribed a glucagon emergency kit for home use.When should the nurse instruct the patient and family that glucagon needs to be administered?

Correct Answer is B

Explanation

After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.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?