what should the nurse monitor when administering opioids to a patient

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. What should be monitored when administering opioids to a patient?

A. Monitor blood pressure
B. Monitor respiratory rate
C. Monitor heart rate
D. Monitor oxygen saturation

Correct answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.

2. A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?

A. Lie down after meals to reduce discomfort.
B. Limit fluid intake to 1 liter per day.
C. Avoid eating spicy foods.
D. Eat three large meals each day.

Correct answer: C

Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.

3. A nurse is assessing a client who has a history of gastroesophageal reflux disease (GERD). Which of the following findings should the nurse identify as a complication of GERD?

A. Hematemesis.
B. Melena.
C. Pallor.
D. Steatorrhea.

Correct answer: A

Rationale: The correct answer is A: Hematemesis. Hematemesis (vomiting blood) is a sign of gastrointestinal bleeding and a serious complication of GERD. Melena (black, tarry stool) is also a sign of GI bleeding but is not as specific to GERD as hematemesis. Pallor may be present due to anemia from chronic blood loss, but it is not a direct complication of GERD. Steatorrhea is not typically associated with GERD; it is more indicative of malabsorption issues.

4. How should fluid balance in a patient with heart failure be monitored?

A. Monitor daily weight
B. Monitor input and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

5. How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?

A. Encourage compliance through education
B. Contact the healthcare provider
C. Document the refusal
D. Explore alternative treatment options

Correct answer: A

Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.