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 A

Explanation

Choice A reason: Octreotide reduces portal hypertension and bleeding in esophageal varices by constricting splanchnic blood flow. This aligns with acute variceal bleed management, making it the correct medication the nurse would expect to be administered to the actively bleeding client.

Choice B reason: Propranolol prevents variceal bleeding long-term but is not used for active bleeding. Octreotide is acute treatment, making this incorrect, as it’s inappropriate for the nurse’s expectation in managing the client’s immediate esophageal variceal hemorrhage.

Choice C reason: Lactulose treats hepatic encephalopathy, not active variceal bleeding. Octreotide controls acute hemorrhage, making this incorrect, as it’s unrelated to the nurse’s priority of administering a medication to stop the client’s esophageal variceal bleeding in the emergency.

Choice D reason: Spironolactone manages ascites in liver disease, not acute variceal bleeding. Octreotide is the treatment for active bleeding, making this incorrect, as it’s irrelevant to the nurse’s expectation for a medication to control the client’s esophageal variceal hemorrhage.

A. Failure to analyze the level of care needed by the patient. B. Failure to respect the patient’s wishes. C. Wrongful death. D. Failure to take appropriate action.

Correct Answer is D

Explanation

Choice A reason: Analyzing care levels is important, but the nurse’s negligence lies in not addressing the critical magnesium level. Reporting to the practitioner is the appropriate action, making this incorrect, as it’s less specific than the failure to act on a critical lab result.

Choice B reason: Respecting patient wishes relates to DNR but doesn’t negate the need to report critical labs for non-resuscitative care. Failure to act is the issue, making this incorrect, as it misapplies the DNR to the nurse’s duty to address the magnesium level.

Choice C reason: Wrongful death assumes patient harm or death, which isn’t indicated here. Failure to act on the critical magnesium level is the negligence, making this incorrect, as it overstates the outcome compared to the nurse’s inaction on the lab result.

Choice D reason: Failure to take appropriate action, such as reporting a critical magnesium level of 1.1 mEq/L, is negligent, regardless of DNR status. This aligns with nursing standards, making it the correct action the nurse neglected, as critical labs require practitioner notification.

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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

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

Correct Answer is A

Explanation

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

Correct Answer is D

Explanation

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

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Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?