Nokea
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.
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A client is prescribed naloxone. The nurse would expect to administer the drug by which route?
- A. IM injection
- B. IV push
- C. Intrathecal injection
- D. IV piggyback
- E. Subcutaneous injection
Correct Answer: B,D
Rationale: Naloxone (Narcan) is administered by IV infusion requiring the use of a secondary line, an IV piggyback, or an IV push.
When administering an opioid antagonist, the nurse would expect reversal of which of the following opioid effects?
- A. Respiratory depression
- B. Constipation
- C. Analgesia
- D. Hypotension
- E. Bradycardia
Correct Answer: A,B,C,D,E
Rationale: Opioid antagonists are not selective for reversal of specific adverse reactions occurring with the use of an opioid but will reverse all adverse reactions caused by opioids.
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.
A client is given a postoperative opioid drug for pain relief. The nurse observes that the drug has slowed the client's breathing pattern. Which of the following reasons would the nurse most likely identify as the cause of the lowered breathing pattern?
- A. Anxiety
- B. Somnolence
- C. Nausea
- D. Anorexia
Correct Answer: B
Rationale: The nurse should identify somnolence as a cause of slowing of the client's breathing pattern. Sometimes the somnolence and pain relief produced by the opioid drug can slow the client's breathing pattern. Anxiety, nausea, and anorexia are not known to be responsible for slowing down a client's breathing pattern when the client is administered an opioid drug.
An opioid-naïve client experiences acute pain after surgery and is prescribed opioid therapy. The nurse would be especially alert for the development of which of the following?
- A. Pruritus
- B. Severe headache
- C. Respiratory depression
- D. Urticaria
Correct Answer: C
Rationale: The nurse should monitor for symptoms of respiratory depression developing in the client as one of the severe adverse reactions of opioid treatment. Pruritus, urticaria, and headache are caused by opioids, but these conditions are not the most severe and common adverse reactions observed in opioid-naïve clients.