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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Do slow position changes to avoid falls from lowering blood pressure: This is not the priority teaching point for an anticholinergic medication. While some anticholinergics can cause orthostatic hypotension, the risk of urinary retention is a more significant concern.
B. If you feel short of breath, use a rescue inhaler: This instruction is unrelated to the use of anticholinergic medication and may be more relevant for patients with emphysema.
C. "If possible, try to avoid rooms that are cold.": Avoiding cold rooms is not directly related to the use of anticholinergic medication. The priority teaching point should address potential adverse effects specific to the medication.
D. "Make sure to seek care immediately if you're not able to urinate.": Anticholinergic medications can exacerbate urinary retention, particularly in older adults with benign prostatic hyperplasia. It's crucial for the patient to understand the importance of seeking medical attention if they experience difficulty urinating.
Correct Answer is ["A","C"]
Explanation
A. Increased heart rate: Sympathetic nervous system stimulation typically leads to increased heart rate as part of the "fight or flight" response.
B. Decrease in urinary bladder muscle tone: Sympathetic stimulation would typically cause relaxation of the urinary bladder, leading to increased muscle tone.
C. Increased blood pressure: Sympathetic nervous system activation results in vasoconstriction and increased cardiac output, leading to elevated blood pressure.
D. Decreased salivation: Sympathetic stimulation can lead to decreased salivation as part of the "fight or flight" response, but it's not a consistent finding.
E. Decreased bowel sounds: Sympathetic activation can inhibit gastrointestinal motility, leading to decreased bowel sounds, but it's not a universal finding in sympathetic stimulation.
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