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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Support system: Spiritual beliefs often provide a supportive community and network of individuals that can help a person navigate illness and difficult situations. A strong support system can positively influence a person's health and well-being.
B. Knowledge that illness is a punishment: This belief is typically negative and may lead to feelings of guilt or despair, which can have a detrimental effect on health. It does not support overall well-being.
C. Endurance of extreme stress: Spiritual beliefs can provide a sense of purpose and strength that helps individuals cope with stress and adversity, promoting resilience in the face of challenges.
D. Positive emotions: Spirituality can foster hope, gratitude, and a sense of peace, all of which can enhance emotional well-being and improve overall health outcomes.
E. Diet: While some spiritual beliefs may have dietary guidelines, not all spiritual practices directly influence diet in a way that enhances health. It is more common for spirituality to affect emotional and mental well-being.
Correct Answer is ["104"]
Explanation
Convert days to hours:
- 1 day 24 hours/day = 24 hours 1
Calculate the hourly rate:
- 2500 mL / 24 hours = 104.1666... mL/hour
Round to the nearest whole number:
- 104 mL/hour
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