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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A) Bright light: Exposure to bright light, especially in the evening or at night, can interfere with the body's production of melatonin, a hormone that regulates the sleep-wake cycle. Bright light exposure can disrupt circadian rhythms, making it more challenging to fall asleep and stay asleep.
B) Drinking caffeinated beverages in the evening: Caffeine is a stimulant that can interfere with sleep by blocking the effects of adenosine, a neurotransmitter that promotes sleepiness. Consuming caffeinated beverages in the evening can delay the onset of sleep and reduce overall sleep duration.
C) A 20-minute nap during the day: While short naps can be beneficial for some individuals, especially if they are sleep-deprived, napping for too long or too late in the day can disrupt the body's natural sleep-wake cycle. Short naps can be refreshing, but longer or late-day naps can make it harder to fall asleep at night.
D) Emotional stress: Stress and anxiety can trigger the body's "fight or flight" response, leading to increased alertness and difficulty relaxing or falling asleep. Chronic stress can disrupt the sleep-wake cycle, leading to difficulty initiating or maintaining sleep and resulting in poor sleep quality.
E) A regular bedtime schedule: Having a consistent bedtime schedule can actually help regulate the sleep-wake cycle by reinforcing the body's internal clock. Going to bed and waking up at the same time each day, even on weekends, can help improve sleep quality and make it easier to fall asleep and wake up naturally.
Correct Answer is A
Explanation
A) Socioeconomic:
Stress related to homelessness is categorized as a socioeconomic stressor. Socioeconomic stressors arise from economic or social factors such as poverty, unemployment, housing instability, or lack of access to resources. Homelessness is a significant socioeconomic stressor that can impact various aspects of a person's life, including physical health, mental well-being, and social relationships.
B) Adventitious:
Adventitious stressors refer to unexpected or traumatic events that are outside the individual's control, such as natural disasters, accidents, or crimes. While homelessness can result from various circumstances, it is not typically classified as an adventitious stressor.
C) Cultural:
Cultural stressors pertain to conflicts or challenges related to cultural identity, values, beliefs, or practices. While cultural factors may intersect with the experience of homelessness, the primary stressor in this scenario is socioeconomic rather than cultural.
D) Developmental:
Developmental stressors are related to life transitions or stages of development, such as adolescence, adulthood, or aging. While homelessness can certainly affect individuals at different life stages, the primary stressor in this scenario is the socioeconomic aspect of homelessness rather than a specific developmental stage.
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