A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

temperature

pulse

blood pressure

respirations

Answer and Explanation

The Correct Answer is D

A.   Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B.   Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C.   Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D.   Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.

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Correct Answer is ["A","C"]

Explanation

A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

Correct Answer is ["A","C"]

Explanation

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Correct Answer is D

Explanation

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