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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "It might help if I tried sleeping only on my back."
Sleeping on the back can actually worsen obstructive sleep apnea because gravity can cause the tongue and soft tissues to obstruct the airway more easily. The recommended position to reduce apneic episodes is to sleep on the side.
B. "I’ll sleep better if I take a sleeping pill at night."
Taking a sleeping pill can relax the muscles of the throat, which might worsen sleep apnea by increasing the likelihood of airway obstruction during sleep.
C. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Weight loss is a key factor in reducing the frequency and severity of obstructive sleep apnea. Excess weight, particularly around the neck, can increase the risk of airway obstruction during sleep.
D. "I’ll get a humidifier to run at my bedside at night."
While a humidifier can make the air more comfortable to breathe, it does not directly reduce the number of apneic episodes. It might help with symptoms like dry mouth or nasal congestion but is not a primary treatment for obstructive sleep apnea.
Correct Answer is B
Explanation
A. Placing the soiled linen on the floor before bagging it is unsanitary and violates infection control principles. It increases the risk of spreading pathogens to other surfaces, potentially contaminating the environment.
B. Placing clean linen that touched the floor in the soiled linen bag prevents cross-contamination and maintains cleanliness. It adheres to infection control standards by ensuring that only soiled items are disposed of appropriately.
C. Holding the soiled linen against her body while carrying it to the linen bag risks transferring pathogens to the caregiver's clothing and skin, compromising personal hygiene and promoting contamination.
D. Shaking the soiled linen to remove any toilet paper remnants is ineffective and hazardous. It disperses potentially infectious particles, increasing the risk of contamination and compromising infection control efforts.
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