A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?

Mostly cloudy

Apical heart rate

Blood pressure

Respiratory rate

Level of consciousness

Answer and Explanation

The Correct Answer is D

A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.

B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.

C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.

D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.

E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.

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Correct Answer is B

Explanation

A. Nitrates: Nitrates are primarily used to manage angina or heart conditions and are unrelated to acetazolamide or its potential for allergic reactions.

B. Sulfa-based medications: Acetazolamide is a carbonic anhydrase inhibitor that contains sulfonamide groups. Clients with a sulfa allergy may experience a cross-sensitivity reaction, so it's important to confirm any history of sulfa allergies before administration.

C. Mostly cloudy: This option does not relate to any medication classification and is incorrect.

D. Antilipemic agents: Antilipemics are used to lower cholesterol and are not related to acetazolamide or its potential for allergic reactions.

E. Proton pump inhibitors: Proton pump inhibitors are used to reduce stomach acid and do not have a known cross-sensitivity with acetazolamide.

A. "Remove the patch for two to four hours daily." B. "Apply a new patch each day after waking up." C. "Cover the patch with plastic wrap." D. "Replace the existing patch with a new patch as soon as anginal pain begins."

Correct Answer is B

Explanation

A. "Remove the patch for two to four hours daily.": This is incorrect because transdermal nitroglycerin patches should be worn continuously for 24 hours, with a scheduled time to remove them (usually overnight) to prevent tolerance.

B. "Apply a new patch each day after waking up.": This instruction is correct; clients should apply a new patch daily to ensure continuous therapeutic effects while also allowing a break to reduce tolerance.

C. "Cover the patch with plastic wrap.": This is incorrect; covering the patch with plastic wrap can alter the absorption of the medication and is not necessary.

D. "Replace the existing patch with a new patch as soon as anginal pain begins.": This is incorrect; clients should not replace the patch immediately for angina. Instead, they should use sublingual nitroglycerin for immediate relief and follow the prescribed patch schedule.

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A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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