Answer to Question 1
Correct Answer: 3
Rationale 1: This is subjective data.
Rationale 2: This is subjective data.
Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids.
Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client.
Answer to Question 2
Correct Answer: 1,3,5
Rationale 1: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How often does this happen?
Rationale 2: Asking the client the amount of caffeine ingested during the day might not be appropriate with the client who is experiencing a sleep disturbance.
Rationale 3: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include How do you feel when you wake up in the morning?
Rationale 4: Asking when the client ingests the evening meal might not be appropriate with the client who is experiencing a sleep disturbance.
Rationale 5: Questions appropriate for the nurse to ask during the assessment interview for a client with a sleep disturbance include What have you done to deal with this sleeping problem?