Level: Clinical
Difficulty: Medium
Subtopic: Opioids and pain medications
NCLEX: A 72-year-old client in a long-term care facility is being evaluated for opioid analgesia after surgery. Assessme…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 72-year-old client in a long-term care facility is being evaluated for opioid analgesia after surgery. Assessment data include the client reports dizziness, blood pressure 92/58 mm Hg, and heart rate 118/min after the morning dose. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.