The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?

Pulse rate.

Blood pressure.

Temperature.

Respiratory rate.

Answer and Explanation

The Correct Answer is D

A. Pulse rate:
While monitoring the pulse rate is important for assessing overall cardiovascular function, it is not the most immediate concern when a client becomes lethargic after receiving an opioid. Opioids are known to potentially cause respiratory depression, which is a more critical issue to address first.
B. Blood pressure:
Blood pressure changes can occur with opioid use, but in the context of sudden lethargy, the primary concern is to check for respiratory depression. This condition can lead to significant complications and requires immediate attention.
C. Temperature:
Temperature monitoring is important for identifying infection or other issues, but it is not the most relevant vital sign to assess immediately after noticing lethargy from opioid administration. Respiratory rate is more directly affected by opioids.
D. Respiratory rate:
Opioids can cause respiratory depression, which can lead to lethargy and other serious complications. Assessing the respiratory rate first is crucial to determine if the client is experiencing slowed or irregular breathing, which may require immediate intervention such as administering naloxone or providing supplemental oxygen.

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Correct Answer is A

Explanation

A. Rapid weight gain: Gabapentin is not typically associated with rapid weight gain as a common side effect. However, significant and rapid weight gain can be a concern, as it may indicate fluid retention or other underlying issues that need to be addressed by the healthcare provider. Prompt reporting of such symptoms ensures appropriate evaluation and management.
B. Photosensitivity: Photosensitivity is not a known side effect of gabapentin. While skin reactions can occur with some medications, photosensitivity is not a common issue with gabapentin. The client should be advised to report unusual skin reactions, but photosensitivity is not a specific concern for gabapentin.
C. Gastric irritation: Gastric irritation is not a common side effect of gabapentin. Gabapentin is generally well-tolerated and does not frequently cause gastric problems. If the client experiences significant gastric issues, it should be reported, but it is not a primary concern for this medication.
D. Sexual dysfunction: While sexual dysfunction is not a widely recognized side effect of gabapentin, it can be a concern for some patients. However, rapid weight gain is a more immediate and significant symptom that should be reported to the healthcare provider for further investigation.

A. Polyuria. B. Low urine specific gravity. C. Polydipsia. D. Worsening headache.

Correct Answer is D

Explanation

A. Polyuria: Polyuria, or increased urine output, is typically a symptom of diabetes insipidus (DI) rather than a side effect of vasopressin. Vasopressin is used to treat DI by reducing urine output, so the presence of polyuria might indicate that the medication is not effective or that the dosage needs adjustment.
B. Low urine specific gravity: Low urine specific gravity is also a symptom of DI, reflecting the kidneys' inability to concentrate urine. With the administration of vasopressin, one would expect an improvement in urine concentration and specific gravity, so low urine specific gravity could indicate that the medication is not effectively managing the condition.
C. Polydipsia: Polydipsia, or excessive thirst, is a common symptom of DI. While it may improve with effective vasopressin treatment, its presence alone is not usually an immediate concern requiring healthcare provider notification unless it significantly worsens or is accompanied by other symptoms.
D. Worsening headache: A worsening headache could be a sign of water intoxication or hyponatremia, which can occur if vasopressin causes excessive water retention. This is a serious side effect that requires immediate attention, as it could indicate complications related to vasopressin therapy. The healthcare provider should be notified to assess and address any potential adverse effects of the treatment.

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The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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