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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.
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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 who has been receiving naloxone suddenly starts grimacing and moaning, moving his arms back and forth across his body, and drawing his legs up to his abdomen. Prior to administration the client was sleepy and calm. Assessment reveals that his respiratory rate is 18 breaths per minute. Which nursing diagnosis would most likely apply?
- A. Acute Pain
- B. Impaired Spontaneous Ventilation
- C. Deficient Knowledge
- D. Ineffective Coping
Correct Answer: A
Rationale: The client is exhibiting nonverbal indicators of acute pain, which can result after naloxone reverses the opioid's effects. The client's respiratory rate is 18 breaths per minute, so impaired spontaneous ventilation is not appropriate.
Which of the following are evaluations the nurse should make when caring for a client receiving naloxone?
- A. Pain relief is resumed.
- B. Adverse reactions are identified and managed.
- C. Therapeutic response is achieved.
- D. Client demonstrates an understanding of the drug regimen.
- E. Client's respiratory rate is normal.
Correct Answer: A,B,C,D,E
Rationale: Pain relief is resumed, adverse reactions are identified and managed, therapeutic response is achieved, client demonstrates an understanding of the drug regimen, and client's respiratory rate is normal are evaluations of successful therapy with an opioid antagonist.
A nurse is caring for a client who is receiving naloxone intravenously. The client develops acute pain while the drug is being administered. Which of the following would most likely explain the client's pain level?
- A. The drug was administered as too rapid a dose.
- B. The client's pain wasn't controlled before the administration of naloxone.
- C. The change in respiratory status has caused the increase in pain.
- D. The dosage of the naloxone was too small.
Correct Answer: A
Rationale: When naloxone is given IV and the bolus is given too rapidly, withdrawal symptoms and the return of intense pain occur as the level of opioid is reduced. There is no indication that the client's pain hadn't been controlled previously. A change in the respiratory status does not lead to increased pain. If the dose was too small, the client would still be experiencing some of the effects of the opioid that is being reversed.
A client is prescribed naloxone for the treatment of postoperative acute respiratory depression after a kidney transplant. The nurse explains the drug to the family, describing its action as which of the following?
- A. Naloxone stops internal bleeding.
- B. Naloxone restores respiratory function.
- C. Naloxone restores reflexes of limbs.
- D. Naloxone helps the client overcome pain.
Correct Answer: B
Rationale: The nurse should explain that naloxone restores respiratory function within 1 to 2 minutes after administration. Naloxone neither stops internal bleeding nor restores limb reflexes. Naloxone also does not overcome pain.