A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
Urinary retention
Vomiting
Respiratory rate
Level of consciousness
The Correct Answer is C
A. Urinary retention: While urinary retention can be a side effect of meperidine and other opioids, it is not the priority assessment before administering the medication. Urinary retention is a concern but is not immediately life-threatening compared to other potential side effects of opioids, such as respiratory depression. Assessing urinary retention is important, but it is not the primary concern in this situation.
B. Vomiting: Vomiting can also be a side effect of opioids, including meperidine. While it is essential to assess for vomiting and its potential impact on the client's overall condition, it is not the priority assessment before administering the medication. Vomiting can be managed, and the nurse should address it as needed. However, the priority assessment is one that can affect the client's immediate safety and well-being, such as respiratory rate and potential respiratory depression.
C. Respiratory rate: This is the correct answer. The priority assessment before administering meperidine is the client's respiratory rate. Opioids can cause respiratory depression, leading to reduced breathing and inadequate ventilation. Monitoring the respiratory rate allows the nurse to detect any signs of respiratory distress or inadequate breathing, enabling them to intervene promptly to prevent serious complications.
D. Level of consciousness: While assessing the client's level of consciousness is essential for overall assessment and monitoring, it is not the priority assessment before administering meperidine. Respiratory depression due to opioid use can occur even when the client is conscious. However, if respiratory depression occurs, it can lead to a decrease in consciousness and potentially unconsciousness, making the assessment of respiratory rate more critical to prevent such complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A client with a magnesium level of 3.2 mEq/L has a higher-than-normal magnesium level, indicating hypermagnesemia. The nurse should expect to administer calcium gluconate.
Calcium gluconate is the antidote for hypermagnesemia, as it works to antagonize the effects of magnesium on the body. By administering calcium gluconate, the nurse can help counteract the effects of excess magnesium and normalize the client's magnesium levels.
Let's go through the other options:
B. Calcitonin: Calcitonin is not used to treat hypermagnesemia. Calcitonin is a hormone that regulates calcium and phosphorus levels in the body. It is used in certain conditions, such as hypercalcemia (high calcium levels), but it is not indicated for hypermagnesemia.
C. Magnesium oxide: Magnesium oxide is a form of magnesium supplement, and it is not appropriate for a client with hypermagnesemia, as it would further increase the magnesium level, exacerbating the condition.
D. Magnesium sulphate: Magnesium sulfate is also not appropriate for a client with hypermagnesemia, as it would further elevate the magnesium levels in the body. Magnesium sulfate is often used to treat magnesium deficiency or as a tocolytic agent to prevent premature labor.
Correct Answer is ["B","C","E"]
Explanation
Neostigmine is a medication classified as an acetylcholinesterase inhibitor. It is commonly used to treat myasthenia gravis and to reverse the effects of non-depolarizing neuromuscular blocking agents used during surgery. Adverse reactions to neostigmine are related to its cholinergic effects, which result from increased acetylcholine levels in the body.
Let's go through the options:
A. Hypoactive bowel sounds: Neostigmine can actually increase gastrointestinal motility and may cause increased bowel sounds or even diarrhea, not hypoactive bowel sounds. Therefore, hypoactive bowel sounds are not an adverse reaction to neostigmine.
B. Sweating: Sweating is a cholinergic effect and can be an adverse reaction to neostigmine. Increased sweating is a common sign of cholinergic stimulation.
C. Respiratory distress: Respiratory distress can occur as an adverse reaction to neostigmine, particularly if the client has a history of asthma or other respiratory conditions. Neostigmine can cause bronchoconstriction and excessive secretions, leading to respiratory distress.
D. Urinary retention: Neostigmine is actually used to treat urinary retention by increasing bladder contraction. Therefore, urinary retention is not an adverse reaction to neostigmine.
E. Bradycardia: Bradycardia (slow heart rate) is a significant adverse reaction to neostigmine due to its cholinergic effects on the heart. Increased acetylcholine levels can lead to excessive stimulation of the vagus nerve, resulting in bradycardia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today