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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["37.5"]

Explanation

First, convert the grams to milligrams:

1 gram = 1000 milligrams

So, 4 grams = 4 x 1000 = 4000 milligrams

Now, calculate the infusion rate:

Infusion rate = Desired dose / Concentration

Infusion rate = 300 mg/hour / (4000 mg / 500 mL)

Infusion rate = 300 mg/hour x (500 mL / 4000 mg)

Infusion rate = 37.5 mL/hour

A. Advise the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately. B. Request a prescription to change the route of administration and use the available heparin. C. Calculate and administer the equivalent dose of the available low molecular weight heparin. D. Dilute the available heparin in 250 mL of normal saline solution prior to IV administration.

Correct Answer is A

Explanation

A. Advise the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately: This is the appropriate action. The prescription is for standard heparin, which is different from low molecular weight heparin (LMWH) in both its formulation and use. Standard heparin must be administered intravenously and requires a different preparation than LMWH, which is typically administered subcutaneously. The nurse should request the correct form of heparin (standard heparin) to ensure the client receives the prescribed medication safely and effectively.
B. Request a prescription to change the route of administration and use the available heparin: Changing the route of administration would be inappropriate without proper authorization from the healthcare provider. Low molecular weight heparin is not used for intravenous administration in this context, so this option does not address the need for the correct medication form.
C. Calculate and administer the equivalent dose of the available low molecular weight heparin: Low molecular weight heparin and standard heparin are not interchangeable, and the dosing and administration routes are different. Attempting to convert the dose of LMWH to standard heparin is not advisable without proper guidance, as this could lead to incorrect dosing and potential harm.
D. Dilute the available heparin in 250 mL of normal saline solution prior to IV administration: This is not applicable to low molecular weight heparin. Standard heparin, if available, may require dilution for IV administration, but LMWH is not used for IV administration and should not be substituted in this manner

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes magnesium sulfate 300 mg/hour IV. The IV bag contains magnesium sulfate 4 grams in dextrose 5% in water (D:W) 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["37.5"]

Explanation

A client has a prescription for heparin 1,000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?

Correct Answer is A

Explanation

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client and family that glucagon needs to be administered?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

A client who is taking furosemide reports experiencing leg cramps, a cough, feeling tired, and palpitations. Which action should the nurse take first?

A client with anemia secondary to chronic kidney disease (CKD) started a prescription for epoetin alfa two months ago. Which client finding best indicates that the medication is effective? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers?

A client has a new prescription for diclofenac, a nonsteroidal antiinflammatory drug (NSAID). Which information in the client's history is of greatest concern to the nurse in monitoring the client's response to this medication?

The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?

A client with a fungal infection of the toenail reports to the nurse that the client has been applying an over-the-counter (OTC) triple antibiotic ointment to the infection daily for two weeks without any improvement. Which action should the nurse take?