Which finding in a patient receiving continuous vital-sign monitoring requires the most immediate nursing response?
Correct answer: C. Respiratory rate of 6 breaths per minute after an opioid
- A. Temperature of 37.4°C after a warm blanket
- B. Pulse of 88 beats per minute after quiet rest
- C. Respiratory rate of 6 breaths per minute after an opioid
- D. Blood pressure of 132/78 mmHg before breakfast
Explanation
A respiratory rate of 6 after an opioid suggests potentially life-threatening respiratory depression, so airway and breathing take priority. The other findings are within or near commonly expected adult ranges and do not indicate the same immediate danger.
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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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50 free Vital Signs and Monitoring MCQs from Fundamentals of Nursing, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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