A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

temperature

pulse

blood pressure

respirations

Answer and Explanation

The Correct Answer is D

A.   Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B.   Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C.   Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D.   Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.

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Correct Answer is B

Explanation

A. Palpation may alter bowel sounds, making auscultation after palpation less accurate.
B. Auscultation should be performed before percussion or palpation to prevent interference with the sounds.
C. Checking for kidney tenderness is important but does not affect the timing of auscultating bowel sounds.
D. Inspection should be done before auscultation to assess for any obvious abnormalities before listening for bowel sounds.

A. a drop of 15 to 20 mm Hg from baseline when changing position. B. dizziness upon rising to a standing position. C. blurred vision. D. syncope.

Correct Answer is ["A","B","C","D"]

Explanation

A. A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B. Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C. Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D. Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

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A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

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The nurse taking an apical pulse would place the stethoscope at:

The normal pattern of breathing is described as

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?