The nurse is assessing a client admitted to the ICU and receiving opioid analgesic intravenously. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min

Patient with a temperature of 100.5° F who is asleep but easily roused

Patient with respiratory rate of 10 breaths/min who is breathing deeply

Patient with a respiratory rate of 8 breaths/min who is snoring

Answer and Explanation

The Correct Answer is D

A. Blood pressure and heart rate are not indicators of opioid overdose; these values are within a normal range and do not suggest respiratory depression.
B. A temperature of 100.5°F and sleepiness are concerning but not life-threatening in isolation; the patient is easily aroused, which suggests they are not in respiratory distress.
C. A respiratory rate of 10 breaths/min is low, but if the patient is breathing deeply, they may still be compensating, and further monitoring is necessary.
D. A respiratory rate of 8 breaths/min with snoring is indicative of severe respiratory depression, a life-threatening side effect of opioid use. Immediate intervention is necessary.

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Correct Answer is ["G"]

Explanation

A. History of type 2 diabetes is not a rhythm characteristic seen on an ECG. While diabetes can contribute to the development of cardiovascular issues, it does not specifically describe the characteristics of a third-degree AV block on an ECG.
B. Interval and RR interval are irregular is incorrect. In third-degree AV block (also known as complete heart block), the atrial rate and ventricular rate are typically regular, but the atrial and ventricular rhythms are completely dissociated.
C. Shortened PR interval is incorrect. In third-degree AV block, there is no consistent PR interval because the atria and ventricles are functioning independently.
D. Inconsistently shaped P waves is incorrect. P waves may appear normal, but the relationship between P waves and QRS complexes is lost in third-degree AV block.
E. PR interval is constant is incorrect. In third-degree AV block, the PR interval is inconsistent or absent, as the atrial and ventricular rates are independent of each other.
F. Apical heart rate is irrelevant here. The ECG will show the characteristic findings of third-degree AV block rather than focusing on apical heart rate alone.
G. Fewer QRS complexes than P waves is correct. In third-degree AV block, the atrial impulses (P waves) are conducted normally, but the ventricles are completely dissociated from the atrial rhythm, leading to fewer QRS complexes than P waves, as the ventricles may be paced by an escape rhythm.
H. PP interval is equal to RR interval is not necessarily true in third-degree AV block. The PP and RR intervals may be different depending on the escape rhythm, but they are not usually exactly equal.

A. The patient's head should remain elevated at 45 degrees to avoid aspiration. B. TPN is preferred over the use of enteral feeding to avoid the complication of aspiration. C. Lipid intake should be maintained at greater than 2 g/kg/day. D. Excessive calorie intake can cause an increase in PaCO2

Correct Answer is D

Explanation

A. The head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration, not 45 degrees.
B. Enteral feeding is typically preferred over TPN because it preserves gut integrity and reduces the risk of complications such as infections.
C. Lipid intake should generally be monitored and controlled, but greater than 2 g/kg/day is not recommended and may lead to complications such as hyperlipidemia.
D. Excessive calorie intake, particularly from carbohydrates, can increase carbon dioxide production, leading to a rise in PaCO2 levels in mechanically ventilated patients.

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The nurse is assessing a client admitted to the ICU and receiving opioid analgesic intravenously. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

Correct Answer is ["G"]

Explanation

A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which statement is true?

Correct Answer is D

Explanation

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