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 C

Explanation

C. Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
A. While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.

D. While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.

A. Weight gain B. Distended abdomen C. Confusion D. Dyspnea

Correct Answer is D

Explanation

A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.

C.While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.

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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

Naxlex Comprehensive Predictor Exams

A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's?

Correct Answer is C

Explanation

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?

Correct Answer is D

Explanation

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