A patient receives an opioid for severe pain and 30 minutes later is difficult to rouse with a respiratory rate of 8 per minute. What should the nurse do first?
Correct answer: A. Assess airway and breathing while calling for urgent help
- A. Assess airway and breathing while calling for urgent help
- B. Allow the patient to sleep because pain treatment is expected
- C. Offer the next prescribed dose to prevent pain returning
- D. Complete the medication record before reassessing the patient
Explanation
A respiratory rate of 8 and reduced responsiveness indicate possible opioid-induced respiratory depression. The nurse must immediately assess airway and breathing, summon urgent assistance, and prepare for emergency treatment. Further opioid administration and documentation must not delay life-saving assessment.
Report an error
The more specific you are, the faster it gets fixed. A source beats an opinion.
Prefer email? support@testustad.com
About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
Practise Clinical Judgement and Prioritisation
50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
Discussion
Stuck on an option, or know a faster way to get there? Ask or explain it here.
No comments yet. Be the first to explain this one.
Exams that ask International Nursing Practice questions like this
International Nursing Practice is on 2 papers prepared for on TestUstad, and all of them draw the same bank, so this question is worth knowing for every one of them.
More Clinical Judgement and Prioritisation questions
A registered nurse delegates care to an unlicensed assistive worker for a stable patient. Which task is appropriate to delegate?
The nurse is caring for four patients. Which patient should the nurse assess first?
A patient suddenly develops noisy inspiratory breathing, difficulty speaking, and increasing anxiety. What should the nurse do first?
A patient who is recovering from surgery becomes restless and pale. The heart rate rises from 88 to 124 per minute, the respiratory rate rises to 28, and urine output falls. What is the nurse's priority action?
A patient develops sudden facial drooping and weakness of the right arm while eating breakfast. The patient is awake and breathing normally. What should the nurse do first?
A patient receiving a blood transfusion reports chills, lower back pain, and chest tightness. What is the nurse's first action?