A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Emesis of 250 mL

Increased respiratory rate to 26/min

Decreased anxiety

Decreased urinary output

Answer and Explanation

The Correct Answer is C

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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Correct Answer is D

Explanation

D. Diet plays a crucial role in managing ulcerative colitis symptoms. Certain foods may trigger flare-ups, while others may be better tolerated. A dietitian can provide personalized dietary advice to help manage symptoms, ensure adequate nutrition, and optimize overall health.
A. Ulcerative colitis is a chronic inflammatory bowel disease that primarily affects the colon and rectum. While pain management is crucial, it is not a priority at this point.
B. Hospice services are generally provided to individuals who have a terminal illness and are nearing the end of life. While ulcerative colitis can be a serious condition, it is not typically considered a terminal illness in itself.
C. A wound, ostomy, and continence nurse (WOCN) specializes in the care of patients with ostomies (such as those resulting from surgery for ulcerative colitis), wounds, and continence issues. The client does not require the services at this point as the decision for the surgery has not been made.

A. Massage the client's legs every 4 hr while they are awake. B. Encourage the client to perform circumduction of the feet. C. Limit the client's fluid intake to 2,000 mL daily. D. Keep the client's knees in a flexed position while they are in bed.

Correct Answer is B

Explanation

Feet circumduction increases the activity of calf muscles aiding in venous return. This prevents pooling of blood the deep venous system and hence lowers the risk of DVT

A, C and D have no role in the prevention of DVT

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A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Nursing Test Bank

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