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.

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Free Nursing Study Resources

Correct Answer is ["44"]

Explanation

Calculate the flow rate in mL/hour: 400 mL / 3 hours = 133.33 mL/hour (approximately)

Convert the flow rate to mL/minute: 133.33 mL/hour / 60 minutes/hour = 2.22 mL/minute (approximately)

Calculate the drops per minute: 2.22 mL/minute 20 gtt/mL = 44.4 gtt/minute

Round to the nearest whole number: 44 gtt/minute

A. Ensure that there is an incentive spirometer ready for when the patient gets to the PACU to help prevent atelectasis. B. Provide preoperative teaching about preventing blood clots after surgery. C. Report to the provider that the patient has allergies to sardines. D. Administer the ordered preoperative intravenous antibiotic.

Correct Answer is D

Explanation

A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["44"]

Explanation

A nurse is finalizing preparations for a patient going to surgery in 30 minutes. Which of the following tasks should be the nurse's top priority?

Correct Answer is D

Explanation

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

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