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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Adding the herb can decrease the need for corticosteroids:
There is no substantial evidence to suggest that St. John's Wort affects the need for corticosteroids. This herb's primary concern in the context of a renal transplant is its interaction with other medications rather than altering corticosteroid requirements.
B. The client probably used this herb to treat depression:
While St. John's Wort is commonly used for its antidepressant effects, this information, while relevant, does not directly address the critical issue of drug interactions that can affect transplant medication efficacy.
C. Ingestion of St. John's Wort can reduce the client’s intake of sodium:
St. John's Wort does not have a direct impact on sodium intake or levels. Its primary concern in the context of drug interactions is related to how it affects other medications rather than influencing sodium levels.
D. St. John's Wort can decrease plasma concentrations of cyclosporine:
St. John's Wort is known to interact with various medications, including cyclosporine, by inducing liver enzymes (particularly CYP3A4), which can reduce the plasma concentration of cyclosporine. This interaction is highly significant in the context of a renal transplant, as it can compromise the effectiveness of immunosuppressive therapy and increase the risk of graft rejection.
Correct Answer is ["200"]
Explanation
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
Plugging in the values:
Infusion rate (mL/hr) = 200 mL / 1 hr
Infusion rate (mL/hr) = 200 mL/hr
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