The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?
Pulse rate.
Blood pressure.
Temperature.
Respiratory rate.
The Correct Answer is D
A. Pulse rate:
While monitoring the pulse rate is important for assessing overall cardiovascular function, it is not the most immediate concern when a client becomes lethargic after receiving an opioid. Opioids are known to potentially cause respiratory depression, which is a more critical issue to address first.
B. Blood pressure:
Blood pressure changes can occur with opioid use, but in the context of sudden lethargy, the primary concern is to check for respiratory depression. This condition can lead to significant complications and requires immediate attention.
C. Temperature:
Temperature monitoring is important for identifying infection or other issues, but it is not the most relevant vital sign to assess immediately after noticing lethargy from opioid administration. Respiratory rate is more directly affected by opioids.
D. Respiratory rate:
Opioids can cause respiratory depression, which can lead to lethargy and other serious complications. Assessing the respiratory rate first is crucial to determine if the client is experiencing slowed or irregular breathing, which may require immediate intervention such as administering naloxone or providing supplemental oxygen.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Osteoarthritis: Osteoarthritis is a common condition for which diclofenac is often prescribed. While it is important to monitor the effectiveness of the medication in treating osteoarthritis symptoms, the presence of this condition itself does not pose the greatest concern for the potential side effects or interactions of diclofenac.
B. Chronic alcoholism: Chronic alcoholism is of significant concern when a client is prescribed diclofenac. NSAIDs, including diclofenac, can irritate the gastrointestinal tract and increase the risk of gastrointestinal bleeding or ulcers, a risk that is heightened in individuals with a history of chronic alcoholism. This history makes monitoring for gastrointestinal side effects crucial, as chronic alcohol use can exacerbate these risks.
C. Type 2 diabetes mellitus: While diabetes mellitus can influence overall health and complicate the management of chronic conditions, it is not the most pressing concern related to the use of diclofenac. Diabetes management primarily involves monitoring blood glucose levels and managing diabetes-related complications, rather than the direct side effects of NSAIDs.
D. Migraine headaches: Migraine headaches are not directly related to the side effects or risks associated with diclofenac use. Although NSAIDs can be used to treat migraines, the presence of migraine headaches does not pose as significant a concern regarding the medication’s potential adverse effects as does a history of chronic alcoholism.
Correct Answer is A
Explanation
A. Measure the client's blood pressure: This is the most appropriate action to assess the effectiveness of amlodipine. Amlodipine is a calcium channel blocker primarily used to manage hypertension and angina. Measuring blood pressure will help determine if the medication is effectively lowering the client's blood pressure as intended.
B. Note the client's serum calcium levels: While amlodipine affects calcium channels, its effectiveness is not typically assessed by monitoring serum calcium levels. The primary goal of amlodipine therapy is to manage blood pressure and angina, not to alter serum calcium levels.
C. Monitor the client's serum electrolytes: Monitoring serum electrolytes is important for various conditions and medications, but it is not the primary method to evaluate the effectiveness of amlodipine. Amlodipine’s main action and efficacy are assessed through blood pressure control.
D. Review the client's intake and output: While intake and output are important for overall fluid balance and kidney function, they do not directly measure the effectiveness of amlodipine. The primary assessment for this medication’s effectiveness is through monitoring blood pressure.
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