A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

Pain level

Pulse oximetry

Blood pressure

Level of sedation

Answer and Explanation

The Correct Answer is D

A) Pain level:
While assessing pain is important to determine the effectiveness of the pain management, it is not the immediate priority after administering an opioid.

B) Pulse oximetry:
Monitoring oxygen saturation is critical as opioids can depress respiratory function. However, it is indirectly related to the primary effect of the medication on the central nervous system.

C) Blood pressure:
Monitoring blood pressure is important as opioids can cause hypotension, but it is not as critical as monitoring the level of sedation and respiratory status.

D) Level of sedation:
This is the priority because opioids can cause significant sedation and respiratory depression. Assessing the level of sedation helps determine if the client is at risk of further complications like respiratory arrest. Over-sedation can be a precursor to more serious complications, making this assessment crucial.

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Correct Answer is D

Explanation

A. Light-headedness when standing up:
Elevated potassium levels (hyperkalemia) can lead to muscle weakness or paralysis, cardiac dysrhythmias, and even cardiac arrest. Light-headedness when standing up is more commonly associated with orthostatic hypotension or volume depletion rather than electrolyte imbalances like hyperkalemia.

B. Weak quadriceps muscles:
Weakness in the quadriceps muscles is not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can cause muscle weakness, but it is not specific to the quadriceps.

C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes are not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can lead to hyperreflexia or absent reflexes, but it is not specific to decreased deep tendon reflexes.

D. Tingling of extremities:
This is the correct answer. Hypocalcemia, indicated by the low calcium level in the scenario, can manifest with symptoms such as tingling or numbness of the extremities, muscle cramps, and tetany. Calcium plays a crucial role in nerve transmission, and low levels can lead to sensory disturbances like tingling in the extremities.

A. Contact B. Airborne C. Droplet D. Protective

Correct Answer is D

Explanation

A) Contact: While contact precautions are important for preventing the transmission of infections, they primarily apply to clients with known or suspected infections that can spread through direct or indirect contact with the client or their environment. Protective isolation goes beyond contact precautions and involves comprehensive measures to protect immunocompromised clients from all potential sources of infection.

B) Airborne: Airborne precautions are necessary for clients with infections that spread through the airborne route, such as tuberculosis or measles. While respiratory infections can pose a significant risk to immunocompromised clients, the focus of care for clients after hematopoietic stem-cell transplant is on preventing all types of infections, not just airborne ones.

C) Droplet: Droplet precautions are used for infections transmitted through respiratory droplets expelled when a person coughs, sneezes, or talks, such as influenza or pertussis. While respiratory infections are a concern for immunocompromised clients, the broader approach of protective isolation is more appropriate for clients after hematopoietic stem-cell transplant, as it encompasses all potential routes of infection transmission, not just droplet spread.

D) Protective: Clients who have undergone allogeneic hematopoietic stem-cell transplant are profoundly immunocompromised due to the destruction of their immune system and are highly susceptible to infections. Protective isolation, also known as reverse isolation, is necessary to minimize the risk of infection in these clients. This includes implementing strict infection control measures such as wearing gowns, gloves, masks, and sometimes goggles to prevent exposure to pathogens. Additionally, maintaining a clean environment and limiting visitors and healthcare personnel who may carry infectious agents are essential components of protective isolation.

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A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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