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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This describes a transverse fracture, where the bone breaks completely across and perpendicular to the shaft. It does not describe a greenstick fracture.
B. A spiral fracture is caused by a twisting force, which results in a helical break. This is not a greenstick fracture.
C. A greenstick fracture occurs when the bone bends and cracks on the outer arc but does not break completely through. This type of fracture is more common in children because their bones are softer and more flexible.
D. This describes a comminuted fracture, where the bone breaks into several pieces. It does not match the description of a greenstick fracture.
Correct Answer is B
Explanation
A. Chocolate and peppermint can relax the lower esophageal sphincter, worsening GERD symptoms. These should be avoided.
B. Oatmeal with banana slices is a good choice because it is low in fat and acid, which helps prevent GERD symptoms. Bananas are also a non-acidic fruit that is generally well-tolerated.
C. Spaghetti with tomato sauce contains acidic ingredients that can irritate the esophagus and worsen GERD symptoms.
D. A cheeseburger with grilled onions is high in fat, which can delay gastric emptying and increase reflux. Onions are also a known trigger for GERD symptoms.
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