A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Irritating cough

Tachypnea

Hypertension

Urinary retention

Answer and Explanation

The Correct Answer is D

A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.

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Correct Answer is C

Explanation

A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.

Correct Answer is ["50.9"]

Explanation

Calculation:

To convert pounds to kilograms, use the formula:

Kg = lb/2.2

Substituting the given value:

Kg = 112.2/2.2

= 50.9kg

Thus, 112.2 lb = 50.9 kg.

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A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has been hospitalized after a severe head injury. The nurse recognizes that the client's difficulty in maintaining a normal body temperature when there is no infection present can be the result of which of these?

Correct Answer is C

Explanation

112.2 lb. = _____kg

Correct Answer is ["50.9"]

Explanation

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