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","E","F","G"]
Explanation
O2 saturation: Directly reflects the level of oxygen in the blood.
Respiratory rate 28 bpm: Indicates increased effort to obtain oxygen.
Anxious, Restless: Neurological signs of inadequate oxygenation.
BP 145/89 mmHg: Elevated blood pressure can be a response to hypoxia.
Heart Rate 101 bpm: Increased heart rate is a compensatory mechanism for hypoxia.
Correct Answer is ["A","B","D","E"]
Explanation
A. Confusion can be a sign of a concussion or other injury resulting from a fall, which is a common risk for individuals with Parkinson's disease.
B. Reviewing the client's current food and medication allergies is important as allergies can contribute to confusion if the client is exposed to an allergen.
C. Encouraging increased intake of high protein foods is generally recommended for individuals with Parkinson's disease, but it is not directly related to the acute onset of confusion.
D. Checking the mother's temperature is a direct action to assess for infection, which can be a cause of acute confusion, especially in older adults.
E. Pain with urination could indicate a urinary tract infection, which is another common cause of confusion in the elderly. It is important to assess for this possibility.
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