You are taking care of 4 clients who are receiving opioid analgesics for pain management. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Patient with respiratory rate of 10 breaths/min who is breathing deeply.

Patient with a respiratory rate of 8 breaths/min who is snoring.

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.

Answer and Explanation

The Correct Answer is B

Choice A reason: A respiratory rate of 10 breaths/min with deep breathing is low but less concerning than 8 breaths/min with snoring, indicating potential airway obstruction. Respiratory depression is the primary opioid risk, making this incorrect compared to the more severe respiratory compromise.

Choice B reason: A respiratory rate of 8 breaths/min with snoring suggests severe opioid-induced respiratory depression, a life-threatening side effect requiring immediate intervention. This aligns with opioid safety monitoring, making it the correct patient most likely experiencing a critical opioid adverse effect.

Choice C reason: Elevated blood pressure and heart rate suggest pain or stress, not respiratory depression, the primary opioid danger. A low respiratory rate with snoring is more critical, making this incorrect, as it doesn’t indicate a life-threatening opioid side effect.

Choice D reason: A temperature of 100.5°F and being easily roused suggest mild fever, not respiratory depression. Snoring with a rate of 8 breaths/min is more dangerous, making this incorrect, as it doesn’t reflect a life-threatening opioid effect in the patient.

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Correct Answer is D

Explanation

Choice A reason: Hyperparathyroidism causes hypercalcemia, not hypocalcemia, by increasing calcium levels. Malnutrition in alcoholism depletes calcium, making this incorrect, as it’s the opposite condition compared to the nurse’s recognition of hypocalcemia risk in the client.

Choice B reason: NSAIDs don’t significantly affect calcium levels, unlike malnutrition, which depletes calcium stores. Alcoholism increases hypocalcemia risk, making this incorrect, as it’s not a primary risk factor compared to the nurse’s evaluation of the malnourished client.

Choice C reason: Tetracycline may bind calcium but is less likely to cause hypocalcemia than chronic malnutrition. Alcoholism is a stronger risk, making this incorrect, as it’s a minor factor compared to the nurse’s recognition of hypocalcemia risk in the elderly client.

Choice D reason: A 70-year-old with alcoholism and malnutrition has the greatest hypocalcemia risk due to poor dietary calcium and vitamin D absorption. This aligns with nutritional risk factors, making it the correct client the nurse would recognize as most at risk for hypocalcemia.

A. Shortness of breath. B. Lightheadedness. C. Dry cough. D. Bitter taste in the mouth.

Correct Answer is B

Explanation

Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.

Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.

Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.

Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.

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You are taking care of 4 clients who are receiving opioid analgesics for pain management. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia?

Correct Answer is D

Explanation

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

Correct Answer is B

Explanation

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

After receiving the change-of-shift report, which client does the nurse assess first?