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
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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Related Questions
Correct Answer is ["2525"]
Explanation
To calculate the total intake of the client, the nurse would add up all the fluids administered. The lactated Ringer's IV, which was given at 150 mL/hr for 9 hours, totals 1350 mL. The cefazolin was administered in 100 mL of 0.9% sodium chloride, so that's an additional 100 mL. The two units of packed RBCs are 275 mL and 250 mL, respectively, adding up to 525 mL. The two IV bolus infusions of 250 mL of 0.9% sodium chloride each total 500 mL. Lastly, the famotidine was given in 50 mL of 0.9% sodium chloride, adding another 50 mL. Therefore, the total intake the nurse should record is 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL, which equals 2525 mL.
Correct Answer is D
Explanation
A. Erythrocyte sedimentation rate is not specifically relevant to lithium monitoring.
B. Brain natriuretic peptide is used to diagnose heart failure, not to monitor lithium therapy.
C. Liver function tests are not typically required for lithium monitoring.
D. Thyroid hormone assay is important because long-term lithium use can affect thyroid function, leading to hypothyroidism.
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