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 A

Explanation

A. The client's desire to go home so soon after a significant medical event like an MI suggests a possible denial of the severity of his condition and an unwillingness to acknowledge the
need for further medical care and recovery time.

B. While decisional conflict due to stress could be a concern, the client's behavior does not directly indicate stress about making decisions, but rather a disregard for the gravity of his recent health event.
C. Deficient knowledge of lifestyle changes is likely an issue for someone who has just experienced an MI, but the immediate behavior of wanting to leave the hospital does not directly relate to a lack of knowledge about necessary lifestyle changes.
D. Anxiety related to the treatment plan could be present, but the client's behavior of wanting to leave the hospital suggests a coping mechanism of denial rather than anxiety about the treatment itself.

A. Assess pupillary response to light hourly. B. Initiate seizure precautions. C. Monitor serum potassium frequently. D. Measure urinary output every hour.

Correct Answer is D

Explanation

A. Assess pupillary response to light hourly: Dopamine administration may cause changes in pupillary response, but it is not the primary concern associated with its administration. Hourly pupillary assessment may not be necessary unless other signs of neurological changes are present.

B. Initiate seizure precautions: While dopamine administration may cause neurological effects, such as agitation or tremors, it is not typically associated with seizure activity. Seizure precautions are not indicated solely due to dopamine infusion.

C. Monitor serum potassium frequently: Dopamine administration can affect potassium levels, but monitoring serum potassium levels frequently may not be necessary unless the client has pre- existing potassium imbalances or is at risk for electrolyte disturbances.

D. Measure urinary output every hour: Dopamine is a vasopressor medication that can increase blood pressure and cardiac output, potentially leading to increased renal perfusion and urinary output. Monitoring urinary output hourly is essential to assess the client's response to dopamine therapy and ensure adequate renal function.

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Naxlex Comprehensive Predictor Exams

A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Correct Answer is A

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is D

Explanation

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO to Which on should the nurse include in this client's teaching plan? (Select all that apply)

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

The healthcare provider prescribes regular insulin 8 units/hr intravenously (IV). The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings Which action(s) should the charge nurse take? (Select all that apply)