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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.

B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.

C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.

A. Ensure that the infant's crib mattress is firm. B. Prop the infant with a pillow when in a side-lying position. C. Swaddle the infant in a blanket for sleeping. D. Place the infant in a prone position whenever possible.

Correct Answer is A

Explanation

A. Ensure that the infant's crib mattress is firm. Rationale: A firm mattress reduces the risk of SIDS as it prevents the infant's face from sinking into the mattress, which could obstruct
breathing.
B. Prop the infant with a pillow when in a side-lying position. Rationale: Pillows should not be used with infants due to the risk of suffocation and increased risk of SIDS.
C. Swaddle the infant in a blanket for sleeping. Rationale: While swaddling can be comforting, it should be done correctly to avoid too tight swaddling, which can lead to overheating, another SIDS risk factor.
D. Place the infant in a prone position whenever possible. Rationale: Infants should be placed on their backs to sleep, not on their stomachs, as back-sleeping is associated with a decreased risk of SIDS. Prone sleeping positions are discouraged.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is C

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states. "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?