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
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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Related Questions
Correct Answer is B
Explanation
B. Ondansetron is a commonly used medication for preventing nausea and vomiting induced by chemotherapy. It belongs to a class of drugs called serotonin receptor antagonists, which work by blocking serotonin receptors in the brain and gastrointestinal tract, thereby reducing the sensation of nausea and the urge to vomit. Ondansetron is often administered prior to chemotherapy to help prevent these side effects.
A. Diphenhydramine works by blocking histamine receptors in the brain that trigger nausea and vomiting. However, it is not commonly used as a first-line antiemetic for chemotherapy-induced nausea and vomiting.
C. Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant and is not used specifically for preventing chemotherapy-induced nausea and vomiting.
D. Methylprednisolone is a corticosteroid medication that has anti-inflammatory and immunosuppressant effects.
Correct Answer is A
Explanation
A. Neurovascular assessment should be the nurse's priority assessment. Postoperative patients, especially those who have undergone orthopedic surgery such as ORIF of the femur, are at risk for neurovascular compromise due to factors such as positioning during surgery, edema, and postoperative pain.
B. Pain assessment is important for overall patient comfort and well-being, but in the immediate postoperative period following ORIF of the femur, neurovascular assessment takes priority.
C. The Braden scale is used to assess a patient's risk for pressure ulcers. While pressure ulcer risk assessment is important for overall patient care, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
D. The Morse Fall Risk scale is used to assess a patient's risk for falls. While fall risk assessment is important for patient safety, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
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