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 A

Explanation

A. After breaking the top of the ampule to access the medication, the nurse should dispose of the top portion safely in a sharps container to prevent accidental needlestick injuries and ensure proper disposal of sharps waste.

B. Expelling air into the ampule can increase the pressure inside, potentially causing medication to spill out or splatter when the ampule is opened.
C. To open an ampule safely, the nurse should use an ampule opener around the neck of the ampule to protect their hands from potential injury. By breaking off the top with both hands, the nurse can minimize the risk of accidental cuts or lacerations.
D. Withdrawing medication from an ampule requires the use of a needle and syringe. However, some medications may be supplied in ampules with pre-attached needleless systems for withdrawal.

A. Strawberries B. Eggs C. Peanuts D. Shellfish

Correct Answer is A

Explanation

A. Strawberries aretypically associated with cross-reactivity with latex
B. Eggs are not commonly associated with cross-reactivity with latex.
C. Peanuts are not typically associated with cross-reactivity with latex. Peanut allergy involves specific proteins found in peanuts and is unrelated to latex allergy.

D Shellfish is not associated with cross-sensitivity with latex

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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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