Nokea
A nurse suspects that a client receiving naloxone is experiencing an adverse reaction when the assessment reveals which of the following?
- A. Bradycardia
- B. Dry, flushed skin
- C. Tremors
- D. Diarrhea
Correct Answer: C
Rationale: Generalized reactions to naloxone include nausea and vomiting, sweating, tachycardia, increased blood pressure, and tremors.
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The nurse is evaluating a client who has received naloxone for respiratory depression. Assessment of which of the following would indicate effectiveness of the drug therapy?
- A. Client is now receiving mechanical ventilation.
- B. Client's level of pain has decreased.
- C. Respiratory rate and depth are within acceptable parameters.
- D. Fluid intake and output are balanced.
Correct Answer: C
Rationale: The client receives naloxone to reverse respiratory depression. Therefore, a respiratory rate and depth within acceptable parameters indicate that the drug was effective. The need for mechanical ventilation indicates that the client is still experiencing respiratory difficulty.
A primary health care provider orders opioid antagonist treatment for a client with respiratory depression. The nurse should be aware of which of the following conditions that can occur during an abrupt reversal of opioid respiratory treatment?
- A. Dizziness
- B. Headache
- C. Vomiting
- D. Lightheadedness
Correct Answer: C
Rationale: The nurse should know that an abrupt reversal of opioid respiratory depression with an opioid antagonist results in vomiting. The nurse must maintain a patent airway and should turn and suction the client as needed in such cases. Headache, dizziness, and lightheadedness are not known to occur during an abrupt reversal of opioid respiratory treatment.
A client with chronic back pain is admitted to a local health care facility for respiratory depression secondary to an inadvertent overdose of his opioid analgesic. The client is to receive naloxone. Which of the following would the nurse include before administering naloxone?
- A. Monitor the client's blood pressure every 5 minutes.
- B. Review the client's allergy history and treatment modalities.
- C. Monitor vital signs every 5 to 15 minutes if the client is responsive.
- D. Monitor respiratory rate and rhythm of the client.
Correct Answer: B
Rationale: Before administering the antagonist, the nurse should review the client's initial health history, allergy history, and treatment modalities. The nurse should also obtain the client's blood pressure, pulse, and respiratory rate and review the record for the drug suspected of causing the symptoms of respiratory depression. All these interventions are part of the preadministration assessment.
A client is receiving an opioid antagonist. The nurse would closely monitor the client for which of the following?
- A. Cramps
- B. Sweating
- C. Low blood pressure
- D. Skin inflammation
Correct Answer: B
Rationale: The nurse should monitor for sweating when caring for the client since it is one of the adverse reactions of opioid antagonists. Other adverse reactions include nausea, vomiting, tachycardia, increased blood pressure, and tremors. The nurse need not monitor for cramps, low blood pressure, or skin inflammation since these conditions are not known to be caused by opioid antagonists.
After administering naloxone to a client with respiratory depression, the nurse would expect to see the effects of the drug within which time frame?
- A. 1 to 2 minutes
- B. 3 to 4 minutes
- C. 5 to 6 minutes
- D. 7 to 8 minutes
Correct Answer: A
Rationale: Naloxone is capable of restoring respiratory function within 1 to 2 minutes after administration.