A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

Pain level

Pulse oximetry

Blood pressure

Level of sedation

Answer and Explanation

The Correct Answer is D

A) Pain level:
While assessing pain is important to determine the effectiveness of the pain management, it is not the immediate priority after administering an opioid.

B) Pulse oximetry:
Monitoring oxygen saturation is critical as opioids can depress respiratory function. However, it is indirectly related to the primary effect of the medication on the central nervous system.

C) Blood pressure:
Monitoring blood pressure is important as opioids can cause hypotension, but it is not as critical as monitoring the level of sedation and respiratory status.

D) Level of sedation:
This is the priority because opioids can cause significant sedation and respiratory depression. Assessing the level of sedation helps determine if the client is at risk of further complications like respiratory arrest. Over-sedation can be a precursor to more serious complications, making this assessment crucial.

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Correct Answer is B

Explanation

A) The client with end-stage renal failure scheduled for dialysis is at risk for fluid volume excess rather than deficit. Dialysis is a treatment to remove excess fluid and waste products from the body, which can lead to fluid volume deficit if not managed appropriately, but the scenario does not indicate current dehydration.

B) The client with gastroenteritis and fever is at risk for fluid volume deficit due to fluid loss from vomiting, diarrhea, and fever-induced diaphoresis. Gastroenteritis commonly leads to dehydration, especially when accompanied by fever, which increases fluid loss through sweating.

C) The client with left-sided heart failure and an elevated brain natriuretic peptide (BNP) level is at risk for fluid volume excess rather than deficit. Elevated BNP levels indicate heart failure, which can result in fluid retention and volume overload rather than deficit.

D) The client who has been NPO since midnight for endoscopy is at risk for fluid volume deficit due to fasting. However, the severity and duration of fasting are not specified in the scenario, so it may not present an immediate risk compared to the client with gastroenteritis and fever.

A. a 41-year-old with hypernatremia B. a 72-year-old with chronic alcoholism C. a 79-year-old with bone cancer D. a 46-year-old with respiratory acidosis

Correct Answer is B

Explanation

A) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.

B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.

C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.

D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.

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A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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