A nurse is administering morphine sulfate intravenously to a client who has acute pain due to a kidney stone. Which of the following actions should the nurse take?
Dilute the medication in 50 mL of normal saline
Inject the medication over 1 to 2 minutes
Flush the IV line with heparin before and after administration
Monitor the client's respiratory rate every 15 minutes
The Correct Answer is B
A) Incorrect. Morphine sulfate does not need to be diluted in normal saline before administration. Diluting the medication can reduce its potency and effectiveness.
B) Correct. Morphine sulfate should be injected slowly over 1 to 2 minutes to prevent adverse effects, such as hypotension, respiratory depression, and nausea.
C) Incorrect. Heparin is not indicated for flushing the IV line before and after administration of morphine sulfate. Heparin is an anticoagulant that can increase the risk of bleeding. The IV line should be flushed with normal saline or sterile water to prevent medication incompatibility and ensure complete delivery of the medication.
D) Incorrect. The nurse should monitor the client's respiratory rate more frequently than every 15 minutes, as morphine sulfate can cause respiratory depression. The nurse should monitor the client's respiratory rate before, during, and after administration of the medication, and at least every 5 minutes until the client's pain is relieved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Diarrhea is a common side effect of amoxicillin, but it is not a sign of an allergic reaction. The nurse should advise the client to drink plenty of fluids and eat foods that are high in fiber to prevent dehydration and constipation. The nurse should also instruct the client to report severe or bloody diarrhea, as it may indicate a serious condition called pseudomembranous colitis.
B) Correct. Rash is a sign of an allergic reaction to amoxicillin, and it may indicate a hypersensitivity or anaphylactic reaction. The nurse should instruct the client to report any rash, itching, hives, or swelling to their provider immediately and stop taking the medication.
C) Incorrect. Headache is a common side effect of amoxicillin, but it is not a sign of an allergic reaction. The nurse should advise the client to take over-the-counter analgesics, such as acetaminophen or ibuprofen, to relieve headache pain.
D) Incorrect. Nausea is a common side effect of amoxicillin, but it is not a sign of an allergic reaction. The nurse should advise the client to take the medication with food or milk to reduce nausea and vomiting.
Correct Answer is A
Explanation
A) Incorrect. The client should eat a consistent amount of foods that are high in vitamin K, such as leafy greens, broccoli, and cabbage. Vitamin K can interfere with the anticoagulant effect of warfarin and increase the risk of clotting.
B) Correct. The client should use an electric razor for shaving to prevent cuts and bleeding.
C) Correct. The client should check their blood pressure regularly to monitor for hypertension, which can increase the risk of bleeding complications.
D) Correct. The client should report any signs of bleeding or bruising to their provider, as they may indicate a high INR level or a bleeding disorder.
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