Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. What is your priority assessment?
A) Assessment for decreased level of consciousness (LOC)
B) Assessment for respiratory depression
C) Assessment for fluid overload
D) Assessment for paradoxical increase in pain
Ans: B
Feedback:
A patient who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic, though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances.
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The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure?
A) 46 mm Hg B) 99 mm Hg C) 198 mm Hg D) 76 mm Hg
When obtaining a client's history, the nurse suspects that the client is manifesting the prodromal symptoms of genital herpes when the client describes:
A) nausea and vomiting. B) suprapubic pain radiating toward the small of the back. C) dysuria and difficulty starting and stopping the stream of urine. D) burning, throbbing pain in the genital area.
Collecting information about a person is:
a. Assessment b. Gossip c. Implementation d. Evaluation
Which would be considered agents in the epidemiologic triad?
a. Flexible management styles of the authorities b. Temperature extremes and crowding c. Susceptible human beings d. High-risks groups of individuals