The client is a 42-year-old female who had a right above-the- knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What actions should the nurse take to assure safety morphine administration? Select all that apply.
Suction the client to clear the airway
Restrain the client with soft restraints
Perform a 12-lead electrocardiogram
Have a manual resuscitation bag at the bedside
Ask the client about other medications she takes
Take an initial respiratory rate
Correct Answer : E,F
A. Suctioning the client to clear the airway is not directly related to the administration of morphine and is typically not a routine precaution unless the patient has a specific need.
B. Using soft restraints is not a standard safety measure for morphine administration and could be considered if the patient has a history of confusion or agitation, but there is no such indication in this scenario.
C. Performing a 12-lead electrocardiogram is not a standard procedure for ensuring the safe administration of morphine and is usually done for cardiac assessment.
D. Having a manual resuscitation bag at the bedside is a good practice in case of an emergency but is not specific to morphine administration safety.
E. Asking the client about other medications she takes is crucial to prevent drug interactions, as morphine can interact with many medications, potentially leading to adverse effects.
F. Taking an initial respiratory rate is important because morphine can cause respiratory depression, and it is essential to have a baseline to monitor for any changes after administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Secure chest tube to the stretcher for transport: While securing the chest tube is important to prevent dislodgement during transport, the priority is to ensure proper drainage and prevent air leaks by keeping the chest tube container below the site of insertion.
B. Mark the amount of chest drainage on the container: While it's important to document chest drainage, ensuring proper drainage by keeping the container below the insertion site takes precedence, especially during transport.
C. Keep the chest tube container below the site of insertion: Correct! Keeping the chest tube
container below the site of insertion ensures continuous drainage of air and fluid from the pleural space, which is crucial for maintaining respiratory function and preventing complications such as pneumothorax.
D. Administer PRN pain medication prior to transport: Pain management is important, but in this urgent situation, maintaining proper chest tube function and respiratory support is the priority.
Correct Answer is D
Explanation
A. Securing the chest tube to the stretcher is important, but not the most critical action as it does not directly affect the function of the chest tube during transport.
B. Administering pain medication is important for comfort but is not the most immediate concern during urgent transport for a CT scan.
C. Marking the amount of chest drainage is a routine monitoring action and can be done before or after transport, thus not the most critical action.
D. Keeping the chest tube container below the site of insertion is crucial to maintain proper
drainage by gravity and prevent complications such as tension pneumothorax, which can be life- threatening.
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