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.

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Correct Answer is ["A","E","F"]

Explanation

Rationale for Correct Choices:

The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

A. Demonstrate to the PN how to position the client more effectively for the procedure. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Assume care of the client and assign the PN to the care of a different client. D. Acknowledge that the PN has positioned the client safely and correctly.

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure: The nurse is responsible for ensuring correct positioning to optimize visualization and safety during a sigmoidoscopy. Providing guidance or demonstration supports safe practice and enhances the PN’s competence.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: While additional assistance may be helpful, it does not address whether the client is positioned correctly, which is the immediate priority for procedural safety and effectiveness.

C. Assume care of the client and assign the PN to the care of a different client: Reassigning responsibilities may delay the procedure and does not utilize the opportunity for the PN to learn proper technique. Collaboration and teaching are preferred.

D. Acknowledge that the PN has positioned the client safely and correctly: Simply acknowledging the position without verifying or guiding may result in suboptimal visualization or risk to the client. The nurse must ensure accuracy rather than assume correctness.

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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

Correct Answer is ["A","E","F"]

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?

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?

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA).The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

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 ______________