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 D
Explanation
A. Fidelity refers to being loyal, faithful, and keeping promises, but it is not the primary principle when obtaining informed consent.
B. Nonmaleficence means "do no harm," which is important in healthcare but does not directly relate to the process of informed consent.
C. Beneficence involves promoting good and acting in the best interest of the patient but is secondary to ensuring informed consent is given.
D. Veracity is the ethical principle of truth-telling. It is most important when obtaining informed consent because the patient must fully understand the information about the procedure, including the risks and benefits, before giving consent.
Correct Answer is A
Explanation
A. Deep breathing and holding can help relax the patient, reduce pain perception, and enhance the effects of opioid medications.
B. Ambulating may be appropriate but should be done carefully, as it could exacerbate pain or cause dizziness after opioid administration.
C. While distraction like watching TV can help manage pain, it is not as effective as active pain-relieving interventions like deep breathing.
D. Applying ice to the incision site can be helpful for pain management, but deep breathing is more directly beneficial for managing postoperative pain.
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