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The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.
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A client with type I diabetes mellitus has been prescribed a glucagon emergency kit for home use. When should the nurse instruct the client and family to administer glucagon?
- A. Prior to meals to prevent hyperglycemia.
- B. When symptoms of severe hypoglycemia are present.
- C. When the client is unable to eat during sick days.
- D. At the onset of symptoms of diabetic ketoacidosis.
Correct Answer: B
Rationale: This question is identical to Question 25. Glucagon is for severe hypoglycemia (B), not hyperglycemia (A), sick days (C), or ketoacidosis (D). Note: Duplicate question; consider removing.
A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?
- A. Determine when the last dose was administered.
- B. Review the history for past use of recreational drugs.
- C. Ask the client to rate the current level of pain using a pain scale.
- D. Encourage the client to use diversional thoughts to manage pain.
Correct Answer: C
Rationale: Assessing the client’s pain level using a pain scale (C) is the first step to quantify pain and guide appropriate dosing. Determining the last dose (A) and reviewing drug history (B) are secondary. Diversional thoughts (D) are a non-pharmacological adjunct, not the priority.
Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?
- A. Assess for hypoglycemia between meals.
- B. Check blood glucose levels every six hours.
- C. Provide meals at the same time this insulin is given.
- D. Keep an oral liquid or glucose source available.
Correct Answer: C
Rationale: Insulin lispro, a rapid-acting insulin, peaks quickly and should be given with meals (C) to match food intake and prevent hypoglycemia. Assessing for hypoglycemia (A) and keeping glucose sources (D) are important but secondary. Six-hour glucose checks (B) are too infrequent.
A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client’s plan of care?
- A. Replace salt with a salt substitute.
- B. Cover your skin before going outside.
- C. Limit intake of high-potassium foods.
- D. Monitor skin for excessive bruising.
Correct Answer: C
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia. Limiting high-potassium foods (C) prevents this risk. Salt substitutes (A) often contain potassium, worsening hyperkalemia. Sun protection (B) and bruising (D) are unrelated to spironolactone’s primary risks.
A patient who is taking albendazole reports experiencing fatigue, nausea, and dark urine. The nurse observes a yellowing of the patient’s skin and sclera. Which laboratory result should the nurse review?
- A. Thyroid function test.
- B. Liver function test.
- C. Renal function panel.
- D. Basic metabolic panel.
Correct Answer: B
Rationale: Albendazole can cause hepatotoxicity, indicated by fatigue, nausea, dark urine, and jaundice. Reviewing liver function tests (B) assesses damage. Thyroid (A), renal (C), and metabolic panels (D) are unrelated to these symptoms.