Within 15 minutes after receiving a dose of morphine sulfate, the patient is very tired, and their respirations are shallow, with a rate of 6 breaths/minute.
Which priority action does the nurse prepare for at this time?
Apply O2 at 2 L.
Administration of naloxone.
Administration of flumazenil.
Immediate intubation and artificial ventilation.
The Correct Answer is B
This question addresses the emergency management of opioid-induced respiratory depression. The nurse must recognize signs of overdose, specifically bradypnea (normal rate 12 to 20 breaths/minute), and act immediately to administer a specific pharmacological antagonist to reverse opioid receptor binding and restore stable respiratory function.
Choice A rationale
Oxygen administration provides supportive care but does not address the underlying cause of respiratory depression. Opioids must be reversed at the receptor level to restore the brain's drive to breathe, making oxygen a secondary intervention in an acute opioid toxicity crisis.
Choice B rationale
Naloxone is a competitive opioid antagonist that rapidly displaces opioids from receptors. It is the specific antidote for morphine-induced respiratory depression and will restore the patient's normal respiratory rate and prevent further hypoxemia and the risk of cardiac arrest.
Choice C rationale
Flumazenil is the specific antidote for benzodiazepine overdose. It has no pharmacological effect on opioid receptors and would be completely ineffective in reversing the respiratory depression caused by morphine, leaving the patient at high risk for ongoing respiratory failure.
Choice D rationale
Intubation is reserved for cases where pharmacological reversal fails or the airway cannot be protected. In this acute opioid overdose, administration of naloxone is the first-line intervention that can quickly reverse the respiratory depression without the risks associated with invasive intubation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This question tests the safe administration of low-molecular-weight heparin. It requires knowledge of syringe design and subcutaneous injection technique, specifically the necessity of maintaining the air bubble to ensure the full dose of medication is delivered and to prevent drug loss in the needle hub.
Choice A rationale
Enoxaparin is administered via subcutaneous injection. Aspirating before depressing the plunger is not indicated for this route, as there is no significant risk of hitting a large blood vessel that would require this maneuver for safety.
Choice B rationale
The injection site for enoxaparin should be at least 5 cm (2 inches) away from the umbilicus. Injecting too close to the navel increases the risk of local bruising and hematoma formation due to the high vascularity of that area.
Choice C rationale
Prefilled syringes for enoxaparin are designed with an air bubble to ensure the entire prescribed dose is delivered. Expelling this bubble can lead to an incomplete dose, which is clinically significant when administering anticoagulants for therapeutic, weight-based management.
Choice D rationale
Subcutaneous injections are typically administered at a 90 degree angle if enough adipose tissue is grasped to avoid intramuscular injection. Using a 45 degree angle is generally reserved for patients with very little subcutaneous tissue to ensure proper delivery.
Correct Answer is {"dropdown-group-1":"A"}
Explanation
This question assesses knowledge of pharmacological categories and their indications. It requires matching a specific medication with its primary clinical action, which is essential for ensuring accurate medication administration and understanding the intended therapeutic outcome for patients with gastrointestinal motility concerns.
Choice A rationale
Docusate sodium is a stool softener. It works as a surfactant to decrease the surface tension of stool, allowing water and lipids to penetrate the fecal mass, which results in softer stools that are easier to pass during defecation.
Choice B rationale
Stimulant laxatives, such as bisacodyl or senna, are used to stimulate peristalsis and cause a bowel movement. Docusate sodium does not stimulate intestinal motility and is not indicated for stimulating a bowel movement in patients with constipation.
Choice C rationale
Lactulose is the medication used to treat high ammonia levels, typically associated with hepatic encephalopathy. It works by preventing the absorption of ammonia in the colon. Docusate sodium has no role in the management of hyperammonemia.
Choice D rationale
GERD is treated with proton pump inhibitors, H2 receptor antagonists, or antacids. Docusate sodium is a stool softener and has no effect on stomach acid production or the treatment of gastroesophageal reflux disease symptoms in patients.
Choice E rationale
Sucralfate is the medication that coats and protects ulcers in the gastrointestinal tract. It works by creating a protective barrier over the ulcerated tissue. Docusate sodium does not provide any mucosal protection for peptic or gastric ulcers.
Choice F rationale
Megestrol acetate is an example of an appetite stimulant used in patients with cachexia or weight loss. Docusate sodium is a stool softener used for constipation and does not have any pharmacological effect on the appetite of patients.
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