A patient who received an opioid is difficult to arouse and has a respiratory rate of 8 per minute. What is the nurse’s priority action?
Correct answer: A. Assess the airway and breathing while calling for urgent help
- A. Assess the airway and breathing while calling for urgent help
- B. Allow the patient to sleep and reassess after one hour
- C. Give the next prescribed opioid dose to prevent withdrawal
- D. Offer oral fluids and place the patient in a sitting position
Explanation
A respiratory rate of 8 with reduced consciousness suggests opioid-related respiratory depression, so airway and breathing take priority. The nurse should summon urgent assistance, support ventilation as needed and withhold further opioid until reviewed.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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