Level: Clinical
Difficulty: Medium
Subtopic: Opioids and pain medications
NCLEX: A 34-year-old client on a telemetry unit is being evaluated for opioid analgesia after surgery. Assessment data i…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 34-year-old client on a telemetry unit is being evaluated for opioid analgesia after surgery. Assessment data include blood glucose 54 mg/dL with diaphoresis and confusion. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.