You are the PACU nurse that is caring for a client who has been receiving frequent doses of IV Morphine Sulfate, and opioid pain medication, for post-operative pain. Upon reassessment of the patient you find them unarousable with a decreased level of consciousness, snoring respirations at 10 breaths per minute, and an oxygen saturation of 89%. What should be your first intervention?

Administer oxygen at 4 liters per minute via nasal cannula

Administer Naloxone via IV push

Open the patient's airway with a head tilt.

Place them in the shock position with legs elevated

Answer and Explanation

The Correct Answer is B

A. Administering oxygen is important, but the priority is reversing the opioid-induced respiratory depression with naloxone. Oxygen alone will not address the underlying cause of the decreased level of consciousness.
B. Administering naloxone (Narcan) is the priority intervention because it is an opioid antagonist that will reverse the effects of morphine and other opioids, improving respiratory function and consciousness.
C. Opening the airway is important, but the primary issue here is opioid overdose, which requires naloxone administration for reversal of respiratory depression.
D. Placing the patient in the shock position is not indicated in this scenario. The focus should be on reversing opioid toxicity, not on positioning for shock.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. 50% Dextrose in Water (D50W) IV push is the most appropriate intervention for a client with a blood glucose level of 30 mg/dL, indicating severe hypoglycemia. The rapid administration of D50W will quickly raise the blood glucose level and help restore consciousness.
B. Insulin Regular IV push would lower the blood glucose level, which is not appropriate in this situation where the client is hypoglycemic.
C. 0.9% sodium chloride infusion is a general fluid replacement solution, but it will not address the client's low blood glucose level.
D. 5% Dextrose continuous IV infusion is typically used for maintenance, but it would not act as quickly as D50W to correct severe hypoglycemia in an unconscious patient.

A. Impaired perineal skin integrity B. Protein-calorie malnutrition C. Pain related to abdominal cramping D. Fluid and electrolyte imbalance

Correct Answer is D

Explanation

A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is diabetic and has a blood glucose level of 30 mg/dL. The client is unconscious and has a 20-gauge peripheral IV in the antecubital area. After securing the client's airway, what medication should the nurse plan to administer first?

Correct Answer is A

Explanation

The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

Correct Answer is D

Explanation

Which classification of urinary tract infection (UTI) is described as infection of the kidneys and ureters?

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

The nurse is reviewing laboratory results for a client admitted for renal failure and notes the following: Sodium 144 mEq/L and Potassium 6.6 mEq/L. Which of the following should be the priority intervention?

A client presents to the emergency department with complaints of urinary frequency, dysuria, and fever. Which of the following orders should the nurse carry out first?

Which of the following is a potential complication for a client whose potassium level is 6.5 mEq/L?

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?