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 C

Explanation

Choice A rationale

While it is important to assess for hypoglycemia between meals when a client is receiving insulin lispro, this is not the most important intervention. Hypoglycemia is a potential side effect of all insulins, but the timing of the hypoglycemia is often related to the timing of the insulin dose and meals.

Choice B rationale

Checking blood glucose levels every six hours is a part of diabetes management. However, this is not the most important intervention for a client who is receiving insulin lispro. The timing of blood glucose checks should be individualized based on the client’s needs and the type of insulin they are receiving.

Choice C rationale

Insulin lispro is a rapid-acting insulin that begins to work very quickly. For this reason, it should be given at the same time as meals. This is the most important intervention for a client who is receiving insulin lispro.

Choice D rationale

Keeping an oral liquid or glucose source available is important for all clients with diabetes to treat potential hypoglycemia. However, this is not the most important intervention for a client who is receiving insulin lispro.

A. Praise the patient for her healthy lifestyle and encourage her to maintain her current dietary habits. B. Assure the patient that her dietary choices will enhance the effectiveness of the medication in preventing blood clots. C. Inform the patient that her healthcare provider needs to be informed about her current diet. D. Recommend that the patient substitutes the leafy vegetables with a protein source like nuts or beans.

Correct Answer is C

Explanation

Choice A rationale

While maintaining a healthy lifestyle and diet is generally beneficial, consuming large amounts of leafy green vegetables, which are high in vitamin K, can interfere with the effectiveness of warfarin, a medication that works by inhibiting the action of vitamin K-dependent clotting factors. Therefore, praising the patient for her healthy lifestyle without addressing the potential interaction between her diet and medication could lead to suboptimal treatment outcomes.

Choice B rationale

This statement is misleading. While a healthy diet can contribute to overall health and well- being, the patient’s dietary choices, specifically her daily consumption of leafy green

vegetables, could actually decrease the effectiveness of warfarin. Warfarin’s ability to prevent blood clots is dependent on a consistent intake of vitamin K67.

Choice C rationale

This is the most appropriate response. The healthcare provider should be informed about the patient’s current diet because it could impact the effectiveness of warfarin. The provider may need to adjust the dose of warfarin or provide additional dietary guidance to ensure the medication works as intended.

Choice D rationale

While this might seem like a reasonable suggestion, it’s important to remember that dietary changes should be made in consultation with a healthcare provider or a dietitian. Substituting leafy green vegetables with other protein sources may not be necessary or appropriate depending on the patient’s overall diet, nutritional needs, and personal preferences.

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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

Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?

Correct Answer is C

Explanation

A female patient who follows a vegetarian diet has recently been prescribed warfarin. She mentions that she consumes leafy green vegetables daily.What should be the nurse’s response?

Correct Answer is C

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?