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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","D","E","G","H"]

Explanation

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

A. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet. B. Seek clarification of the type of advance directive the client has. C. Explain that living wills can not be followed by emergency personnel. D. Schedule a client and family conference to review the plan of care.

Correct Answer is B

Explanation

A. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: While verifying a DNR order is important, not all advance directives are represented by a bracelet. This action alone does not clarify the client’s wishes or the specifics of the living will.

B. Seek clarification of the type of advance directive the client has: Living wills and other advance directives vary in scope and specificity. Confirming the type of directive ensures that care aligns with the client’s legally documented wishes and guides future interventions appropriately.

C. Explain that living wills cannot be followed by emergency personnel: Emergency personnel can follow advance directives if they are clearly documented and accessible. Saying they cannot be followed is inaccurate and may create mistrust with the family.

D. Schedule a client and family conference to review the plan of care: A conference may be helpful later for education and care planning, but it does not address the immediate need to clarify the client’s specific directives after an emergency intervention.

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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

Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Correct Answer is ["A","D","E","G","H"]

Explanation

Correct Answer is B

Explanation

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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 ______________