A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient?
The patient's respiratory rate
The appearance of the incision
The date of the patient's last bowel movement
The patient's pulse rate
The Correct Answer is A
A. The patient's respiratory rate: Morphine sulfate is an opioid analgesic that can cause
respiratory depression as a side effect. Therefore, assessing the patient's respiratory rate is crucial before administering the medication to ensure it is within normal limits.
B. The appearance of the incision: While assessing the incision is important for overall surgical site assessment, it's not directly related to the administration of morphine sulfate.
C. The date of the patient's last bowel movement: Bowel movements may be impacted by anesthesia and surgery, but they are not directly relevant to assessing the safety of administering morphine sulfate.
D. The patient's pulse rate: Pulse rate is important for overall assessment of the patient's
condition but may not directly indicate the need for or safety of administering morphine sulfate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will need to take extra care of my teeth and gums while on this medication.": Phenytoin can cause gum overgrowth (gingival hyperplasia), so taking extra care of oral hygiene is important.
B. "I will be able to stop taking this drug once the seizures stop.": Phenytoin is typically used as a long-term therapy for seizure control; stopping abruptly can lead to rebound seizures.
C. "I can go out for a beer while on this medication.": Alcohol consumption may interact with phenytoin and should be avoided or limited.
D. "I can skip doses if the side effects bother me.": Skipping doses of phenytoin can lead to inadequate seizure control and should not be done without consulting a healthcare provider.
Correct Answer is C
Explanation
A. CT of the brain can proceed regardless of atropine administration, as it does not directly affect the assessment of brain stem reflexes.
B. Electroencephalogram (EEG) can also proceed regardless of atropine administration, as it evaluates brain electrical activity rather than brain stem reflexes.
C. Assessment of brain stem reflexes should be postponed until all atropine is excreted and no
longer exerting its effects. Atropine can mask or alter the pupillary response and other brain stem reflexes, such as gag reflex and cough reflex, which are important indicators of neurological function.
D. Pupil response assessment should be postponed until atropine effects have dissipated, as
atropine can cause pupillary dilation, which may interfere with accurate assessment of pupil size and reactivity
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