The nurse is caring for a client who received a high amount of fentanyl three hours ago. The nurse understands that she should anticipate a prescription for naloxone (Narcan). Which of the following signs is suggestive of opioid toxicity triad?
Respiration rate of 7 breaths per minute
Anxiety
Fever
Hypertension
The Correct Answer is A
A. Respiratory depression is a hallmark sign of opioid toxicity. A rate of 7 breaths per minute indicates severe respiratory depression, which can be life-threatening and requires immediate intervention with naloxone.
B. Anxiety is not typically associated with opioid toxicity, but rather may be a sign of withdrawal or other conditions.
C. Fever is not a sign of opioid toxicity. It may be a sign of infection or other medical issues.
D. Hypertension is not typical of opioid toxicity; opioids usually cause hypotension, not hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. A client with a history of thromboembolic disease: Estrogen therapy is contraindicated in clients with a history of thromboembolic disease due to the increased risk of blood clots.
B. A client with a history of hypertension: Hypertension is a relative contraindication, but it may still be prescribed with caution.
C. A client with a history of depression: Depression is not a contraindication to estrogen therapy.
D. A client with atypical vaginal bleeding that is not diagnosed: Unexplained vaginal bleeding should be investigated before administering estrogen therapy.
Correct Answer is D
Explanation
A. Loperamide (Imodium): This is an anti-diarrheal medication and does not protect mucosal ulcers.
B. Cimetidine (Tagamet HB): Cimetidine is an H2 blocker used to reduce stomach acid, but it does not form a protective barrier like sucralfate.
C. Docusate sodium (Colace): This is a stool softener and is not used for protecting gastric ulcers.
D. Sucralfate (Carafate): Sucralfate is a mucosal protectant that binds to the ulcer and creates a protective barrier, preventing further injury from stomach acid and pepsin.
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