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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. The tube should be flushed with at least 15–30 mL of water before, between, and after medication administration to prevent clogging and ensure full delivery of the medications.

B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.

C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.

D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.

E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.

A. Transfer to NICU B. Keep in warmer with bilirubin lights C. Bolus of 2 ml/kg glucose 10% IV D. Blood glucose level E. Contact Respiratory Therapy for ABG and oxygen therapy F. Feed immediately G. Apply dextrose (sugar) gel inside the baby's cheek H. Echocardiogram I. Monitor for respiratory distress J. Monitor temperature every 30 minutes

Correct Answer is ["C","D","E","F","I","J"]

Explanation

A. Transfer to NICU - While NICU care is important, immediate stabilization takes precedence.

B. Keep in warmer with bilirubin lights - This is important for thermoregulation and managing jaundice but is not the most immediate concern.

C. Bolus of 2 ml/kg glucose 10% IV - This is critical to address the hypoglycemia (blood glucose 35 mg/dl).

D. Blood glucose level - Monitoring is essential for ongoing assessment of hypoglycemia.

E. Contact Respiratory Therapy for ABG and oxygen therapy - Given the high respiratory rate and potential for respiratory distress, this is a priority.

F. Feed immediately - Feeding can help stabilize blood glucose levels.

G. Apply dextrose (sugar) gel inside the baby's cheek - This is an alternative to IV glucose but less immediate than a bolus.

H. Echocardiogram - Important for cardiac assessment but not an immediate priority.

I. Monitor for respiratory distress - Essential due to the high respiratory rate and risk of complications from maternal diabetes.

J. Monitor temperature every 30 minutes - Important for detecting hypothermia due to the low axillary temperature.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","B","C","D"]

Explanation

Patient data Exhibits The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities Which 6 orders take priority?

Correct Answer is ["C","D","E","F","I","J"]

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?

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 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?

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?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)