A patient in pain requests the prescribed pain medication, which is an opioid. Which nursing assessment is essential before administering the opioid?

Blood pressure

Temperature

Pulse

Respiratory

Answer and Explanation

The Correct Answer is D

Choice A reason: Blood pressure matters but isn’t primary; opioids rarely cause acute hypotension initially, and respiratory depression is a more immediate life-threatening risk.

Choice B reason: Temperature is unrelated; opioids don’t primarily affect fever, and this assessment doesn’t address the critical safety concern of opioid administration.

Choice C reason: Pulse is secondary; opioids may slow heart rate mildly, but respiratory suppression is the urgent risk, requiring priority monitoring before dosing.

Choice D reason: Respiratory rate is critical; opioids depress the brainstem, risking apnea, and assessing breathing ensures safety before administering this high-risk medication.

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Correct Answer is B

Explanation

Choice A reason: Drawing at 8:30 a.m., 60 minutes before, is too early; trough levels, taken just before the next dose, reflect minimum concentration, and this timing risks inaccurate results.

Choice B reason: At 9:00 a.m., 30 minutes before the 9:30 a.m. dose, the trough level accurately measures the lowest vancomycin concentration, ensuring therapeutic monitoring aligns with pharmacokinetics.

Choice C reason: Drawing at 10:00 a.m., after the dose, measures a post-infusion level, not the trough; this timing misses the minimum concentration critical for dosing adjustments.

Choice D reason: At 10:30 a.m., well after the dose, blood reflects peak or random levels, not the trough, skewing data needed to assess vancomycin’s therapeutic efficacy and safety.

A. 62.5 mL/hr B. 125 mL/hr C. 250 mL/hr D. 500 mL/hr

Correct Answer is A

Explanation

Choice A reason: Flow rate is volume divided by time; 250 mL over 4 hours equals 62.5 mL/hr, ensuring safe transfusion pacing to avoid fluid overload or hemolysis.

Choice B reason: 125 mL/hr assumes 250 mL over 2 hours; this doubles the ordered rate, risking circulatory overload and transfusion reactions in a standard protocol.

Choice C reason: 250 mL/hr infuses the unit in 1 hour; this rapid rate exceeds safe limits, potentially causing hypertension or pulmonary edema in vulnerable patients.

Choice D reason: 500 mL/hr is far too fast, implying 250 mL in 30 minutes; this dangerous speed could trigger severe hemolytic reactions or cardiovascular collapse.

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A patient in pain requests the prescribed pain medication, which is an opioid. Which nursing assessment is essential before administering the opioid?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is to administer the patient's next dose of vancomycin at 9:30 a.m. What time will the nurse draw the patient's blood to check the trough vancomycin level?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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