A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
Urinary retention
Vomiting
Respiratory rate
Level of consciousness
The Correct Answer is C
A. Urinary retention: While urinary retention can be a side effect of meperidine and other opioids, it is not the priority assessment before administering the medication. Urinary retention is a concern but is not immediately life-threatening compared to other potential side effects of opioids, such as respiratory depression. Assessing urinary retention is important, but it is not the primary concern in this situation.
B. Vomiting: Vomiting can also be a side effect of opioids, including meperidine. While it is essential to assess for vomiting and its potential impact on the client's overall condition, it is not the priority assessment before administering the medication. Vomiting can be managed, and the nurse should address it as needed. However, the priority assessment is one that can affect the client's immediate safety and well-being, such as respiratory rate and potential respiratory depression.
C. Respiratory rate: This is the correct answer. The priority assessment before administering meperidine is the client's respiratory rate. Opioids can cause respiratory depression, leading to reduced breathing and inadequate ventilation. Monitoring the respiratory rate allows the nurse to detect any signs of respiratory distress or inadequate breathing, enabling them to intervene promptly to prevent serious complications.
D. Level of consciousness: While assessing the client's level of consciousness is essential for overall assessment and monitoring, it is not the priority assessment before administering meperidine. Respiratory depression due to opioid use can occur even when the client is conscious. However, if respiratory depression occurs, it can lead to a decrease in consciousness and potentially unconsciousness, making the assessment of respiratory rate more critical to prevent such complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When providing discharge teaching to a client with a prescription for enoxaparin, the nurse should include the instruction to expel the air bubble prior to injecting the medication. Enoxaparin is a type of anticoagulant medication that is administered as a subcutaneous injection.
Here's why the other options are incorrect:
A. Insert the needle at a 45 angle: Enoxaparin is typically administered as a subcutaneous injection, where the needle is inserted at a 90-degree angle (straight into the skin). A 45-degree angle is used for intramuscular injections, but it is not appropriate for enoxaparin administration.
B. Inject the medication into a muscle: Enoxaparin is not intended to be injected into a muscle. It is a low-molecular-weight heparin designed for subcutaneous administration, meaning it is injected just below the skin into the fatty tissue.
C. Rub the injection site following administration: Rubbing the injection site after administering enoxaparin or any other subcutaneous medication is not recommended. Rubbing the site can cause irritation and bruising. Instead, the nurse should apply gentle pressure with a cotton ball or gauze pad for a few seconds after the injection to help minimize bleeding.
Correct Answer is D
Explanation
TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.
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