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 ["6.7"]
Explanation
600,000 units -> 2 mL
? -> 1 mL
Cross-multiplying:
(600,000 * 1) / 2 = 300,000 units
300,000 units -> 1 mL
2,000,000 units-> ?
Cross-multiplying:
(2,000,000 * 1 ) / 300,000 = 6.67 mL
= 6.7 mL
Correct Answer is A
Explanation
A. Explain that the medication is not given to prevent pain: Scopolamine transdermal patches are primarily used to prevent nausea and vomiting associated with motion sickness or postoperative conditions, not for pain management. This explanation addresses the client's misunderstanding about the purpose of the medication and clarifies that scopolamine is not intended to relieve pain.
B. Offer to apply a new transdermal patch to relieve the pain: This is not appropriate because scopolamine is not used for pain relief. Applying a new patch will not address the client's pain, as the medication's purpose is not related to analgesia.
C. Advise the client that the effects of the medication have worn off: This is incorrect because scopolamine patches are typically used for prophylaxis against nausea and are effective for several days. The medication’s effects should not wear off within a few hours, and the patch is not designed to address pain.
D. Check for correct placement of the patch behind the client's ear: While ensuring the correct placement of the patch is important for its efficacy, the client’s pain indicates a misunderstanding of the patch’s purpose. The patch’s placement is not related to the pain the client is experiencing, as scopolamine is not meant to relieve pain.
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