An older adult patient with a hip fracture became unresponsive 20 minutes after receiving morphine 3 mg intravenously. Which actions would the nurse take?

Correct Answer: C

Rationale: The patient's unresponsiveness after receiving morphine is likely due to opioid-induced respiratory depression, a potentially life-threatening side effect. The nurse should first assess the patient's airway, breathing, and circulation (ABCs) and call for additional assistance. Supporting breathing with a bag-valve-mask device is critical to ensure adequate oxygenation. Naloxone, an opioid antagonist, should be prepared to reverse the effects of morphine. Flumazenil (A) is used for benzodiazepine overdose, not opioids. Reporting a stroke (B) is incorrect because the symptoms are consistent with opioid toxicity, not a stroke. Explaining unresponsiveness as a desired outcome (D) is inappropriate and dangerous.

Correct Answer: B

Rationale: Acetaminophen overdose is hepatotoxic and can cause severe liver damage, leading to liver failure if not treated promptly. The liver metabolizes acetaminophen into a toxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI), which depletes glutathione stores and causes cellular damage. Early administration of N-acetylcysteine (NAC) is critical to prevent irreversible liver damage. While kidney injury can occur, it is less common than liver damage.

Correct Answer: C

Rationale: ACE inhibitors work by inhibiting the enzyme angiotensin-converting enzyme (ACE) in the renin-angiotensin-aldosterone system (RAAS). By inhibiting ACE, the conversion of angiotensin I to angiotensin II is blocked. Angiotensin II is a potent vasoconstrictor and also stimulates the release of aldosterone from the adrenal glands. Aldosterone is a hormone that acts on the kidneys to increase reabsorption of sodium and water, leading to increased blood volume and pressure. By inhibiting aldosterone secretion, ACE inhibitors reduce blood volume and lower blood pressure, making them effective in treating hypertension and heart failure.

Correct Answer: C

Rationale: Amiodarone is the drug of choice for treating severe ventricular dysrhythmias, such as those experienced by the patient in the intensive care unit with acute myocardial infarction. It is a class III antiarrhythmic medication that works by prolonging the action potential duration and refractory period, thereby helping to stabilize the electrical activity of the heart. Amiodarone is effective in treating various types of ventricular dysrhythmias, including ventricular tachycardia and ventricular fibrillation, making it a suitable choice in this scenario. Diltiazem and verapamil are calcium channel blockers primarily used for supraventricular arrhythmias and are not the first-line treatment for severe ventricular dysrhythmias. Adenosine is used for terminating supraventricular tachycardias, not ventricular dysrhythmias. Amiodarone

Correct Answer: D

Rationale: Nesiritide is a synthetic form of brain natriuretic peptide (BNP) that is used for the treatment of acutely decompensated heart failure (HF) in patients who have dyspnea at rest. It works by vasodilating veins and arteries, leading to decreased preload and afterload, thus improving the symptoms of HF such as dyspnea and edema. Nesiritide is typically reserved for patients who are hospitalized with acute decompensated HF and severe symptoms like dyspnea at rest. Patients needing initial treatment for HF or those with atrial fibrillation may not necessarily benefit from nesiritide therapy. Patients with reduced cardiac output may benefit from other therapies aimed at improving cardiac function rather than nesiritide alone.