Difficulty: Medium
Average Score: 63%
Simulated
The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?
Correct answer
D
Rationale
Opioids can cause respiratory depression, a life-threatening side effect presenting as lethargy. Assessing respiratory rate first identifies slowed breathing, guiding urgent interventions like naloxone. Pulse, blood pressure, or temperature are secondary concerns.