A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Bowel sounds

Respiratory rate

Urine output

Pupil reaction

Answer and Explanation

The Correct Answer is B

A. While morphine can affect bowel sounds by causing constipation, this is not the priority assessment before administration.
B. Respiratory rate is the priority assessment because morphine can cause respiratory depression, which is a life-threatening side effect.
C. Urine output is important to monitor for overall kidney function and hydration status but is not the immediate priority before administering morphine.
D. Pupil reaction can indicate opioid effects, but monitoring respiratory status is more critical.

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Correct Answer is A

Explanation

A. Diazepam can cause drowsiness and sedation, so clients should be cautioned about activities that require alertness, such as driving.
B. Avoiding tyramine-containing foods is important for clients taking MAOIs, not diazepam.
C. Diazepam can be taken as a tablet or liquid; it does not necessarily need to be swallowed whole.
D. Grapefruit juice can increase the levels of diazepam in the blood, potentially leading to increased side effects, but it does not inactivate the medication.

A. Carbonated beverage B. Orange juice C. Milk D. Grapefruit juice

Correct Answer is D

Explanation

A. Carbonated beverages can interact with some medications, but they are not as commonly problematic as grapefruit juice.
B. Orange juice does not commonly interact with medications to the same extent as grapefruit juice.
C. Milk can affect the absorption of certain medications, but it is not as broadly problematic as grapefruit juice.
D. Grapefruit juice is known to interact with many medications, potentially leading to dangerous levels of the drug in the bloodstream due to its effect on the cytochrome P450 enzyme system.

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A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Nursing Test Bank

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