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 {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Blank 1
Prepare for defibrillation: The client is unresponsive and has ventricular tachycardia. This indicates a life-threatening arrhythmia. If a patient with VTach is pulseless, the treatment is defibrillation.
Blank 2
Vtach (Ventricular tachycardia): The ECG tracing shows a rapid, wide-complex tachycardia, which is the hallmark of ventricular tachycardia.
Correct Answer is D
Explanation
A. Evaluating the patient's level of consciousness using the Glasgow Coma Scale is important, but it is secondary to ensuring that the airway is open and that breathing is maintained.
B. Informing the patient that the RN-FNE cannot act on the patient's behalf is unnecessary at this point; the priority is immediate medical intervention.
C. Monitoring vital signs, such as blood pressure and pulse, is crucial but secondary to addressing immediate life-threatening conditions like airway compromise.
D. Assessing the patient's airway is the priority because airway compromise is the most critical issue in emergency care. The RN-FNE must stabilize the patient's airway first before proceeding with other assessments.
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