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 C
Explanation
A. Excessive fluid losses may lead to dehydration, but this is not typically a primary concern for patients with pulmonary alterations unless there is significant vomiting, diarrhea, or blood loss.
B. Hemodilution is not a common concern in patients with pulmonary alterations. Hypernatremia typically occurs with fluid loss or inadequate fluid intake, but it is not a direct concern related to pulmonary issues.
C. Fluid volume excess can lead to right-sided heart failure in patients with pulmonary alterations. If fluid accumulates, it can worsen pulmonary symptoms and increase the workload on the heart, potentially leading to right-sided heart failure.
D. Fluid retention with tachypnea is not typically a direct cause of fluid retention. While tachypnea is associated with respiratory distress, fluid retention is more closely linked to heart failure or kidney dysfunction.
Correct Answer is B
Explanation
A. Limiting all nutrients is not recommended for patients on dialysis. While certain nutrients like potassium and phosphorus may need to be restricted, dialysis patients usually require adequate nutrition, especially protein, to support healing and prevent malnutrition.
B. Ensuring an adequate amount of protein is correct. Dialysis patients often experience protein loss through dialysis and need additional protein to prevent catabolism and muscle wasting. Protein intake should be carefully monitored to meet their nutritional needs while avoiding excessive waste buildup.
C. Increasing fluids is not typically advised for dialysis patients, as they often have fluid restrictions due to reduced kidney function and the risk of fluid overload.
D. Encouraging potassium-rich foods is not advisable for patients with renal disease, particularly if they are on dialysis, as they often have issues with potassium retention, which could lead to dangerous hyperkalemia.
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