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.

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Correct Answer is A

Explanation

A. Pupillary constriction: Mydriatic eye drops are designed to dilate the pupils, which means they inhibit pupillary constriction. During the therapeutic period after administration, the pupil remains dilated and does not constrict in response to light or other stimuli.
B. Refraction: Refraction, the bending of light as it passes through the eye's lens and cornea, is not directly affected by mydriatic eye drops. The process of focusing light onto the retina is still functional even when the pupils are dilated.
C. Eye convergence: Eye convergence, the inward movement of both eyes toward each other to focus on a close object, remains functional during mydriasis. Mydriatic drops do not typically impair this ability.
D. Accommodation: Accommodation, the eye's ability to change the focus from distant to near objects, is affected by mydriatic drops. These medications paralyze the ciliary muscles responsible for accommodation, making it difficult to focus on near objects during the period of dilation.

A. Serum ammonia level of 30 μg/dl. (17.62 μmol/dL). B. Hemoglobin level of 13.5 g/dL (135 g/L). C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L). D. Serum glucose level of 120 mg/dL (6.7 mmol/L)

Correct Answer is C

Explanation

A. Serum ammonia level of 30 μg/dl (17.62 μmol/dL):
Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It does not affect serum ammonia levels, which are more relevant in cases of liver dysfunction or urea cycle disorders. Thus, this finding does not indicate the effectiveness of the medication.
B. Hemoglobin level of 13.5 g/dL (135 g/L):
Hemoglobin levels are related to anemia or blood disorders and are not directly affected by sodium polystyrene sulfonate. This lab result would not indicate the effectiveness of the medication in managing potassium levels.
C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L):
Sodium polystyrene sulfonate is specifically used to lower elevated potassium levels. A serum potassium level within the normal range (3.5 to 5 mEq/L) indicates that the medication has been effective in reducing hyperkalemia, which is the primary goal of treatment with this drug.
D. Serum glucose level of 120 mg/dL (6.7 mmol/L):
While glucose levels are important for overall metabolic management, they are not directly impacted by sodium polystyrene sulfonate. This result would not reflect the effectiveness of the medication in treating elevated potassium levels in acute kidney injury.

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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 nurse is assessing the eyes of a client who just received mydriatic eye drops. Which physiological function of the eye will not respond during the therapeutic period after administration of the eye drops?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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