Patient Data

Exhibits

The nurse needs to determine the priority assessment before administering morphine.

Select from Word Choices to complete the sentence.

Before administering morphine, the most important assessment to perform is to check the client's ______________

Temperature

Heart rate

Respiratory rate

Blood pressure

Answer and Explanation

The Correct Answer is C

A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.

B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.

C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.

D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bring a sterile chest drainage unit from central supply to the unit: This task is appropriate for delegation to a UAP because it involves transporting equipment and does not require clinical judgment or assessment.

B. Evaluate a client's urinary catheter for proper drainage: This requires assessment skills to determine whether the catheter is functioning correctly or if complications such as obstruction or infection are present.

C. Call the pharmacy to obtain a client's next antibiotic dose: Communicating directly with the pharmacy about medications is part of the nurse’s responsibilities. It involves ensuring accuracy, safety, and proper coordination of care, which cannot be delegated to unlicensed staff.

D. Observe a client's gait to determine the need for assistance: While a UAP can walk with a client or provide basic support, determining the level of assistance needed requires assessment skills. Evaluating gait involves clinical judgment and must be performed by a licensed nurse or physical therapist.

A. A B. B C. C

Correct Answer is A

Explanation

A. This tablet clearly shows a bisecting score (a single line across the middle). This score is placed by the manufacturer to ensure that when cut, the tablet breaks evenly, and each half contains an approximately equal dose of the medication.

B. The ability to safely cut a tablet in half is indicated by the presence of a score (a line or indentation) on the tablet's surface. These tablets do not have a visible score. Cutting an unscored tablet is unsafe because it can result in uneven dosing.

C. The ability to safely cut a tablet in half is indicated by the presence of a score (a line or indentation) on the tablet's surface. These tablets do not have a visible score. Cutting an unscored tablet is unsafe because it can result in uneven dosing.

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Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

Which oral medication can the nurse safely cut in half?

Correct Answer is A

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

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The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

A client with Parkinson's disease receives a prescription for benztropine. Which common adverse effect(s) should the nurse include in the teaching plan? Select all that apply

Patient Data

Exhibits

The nurse needs to determine the priority assessment before administering morphine.

Select from Word Choices to complete the sentence.

Before administering morphine, the most important assessment to perform is to check the client's ______________