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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Correct Answer is D

Explanation

A. Keep the bed in the lowest position and initiate seizure and fall precautions: While seizure and fall precautions may be necessary for safety, the client's symptoms, including right-sided weakness and sluggish speech, are indicative of a potential stroke rather than a seizure. Immediate intervention to assess for and treat possible stroke is critical.

B. Place an indwelling urinary catheter and measure strict intake and output: Although urinary management may be necessary, it is not the priority in this situation. The client's symptoms suggest a neurological issue that requires urgent assessment and intervention.

C. Maintain elevated positioning of the dependent joints on affected side: Elevating the dependent joints is a strategy used in managing conditions like stroke to prevent complications such as edema, but it does not address the immediate need for stroke assessment and intervention.

D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy: Correct! The client's presentation with right-sided weakness and sluggish speech suggests a possible ischemic stroke. Starting IV access and reviewing inclusion criteria for IV fibrinolytic therapy (tPA is crucial for timely intervention to restore blood flow and minimize neurological damage.

A. Remove the catheter and palpate the client's bladder for residual distention. B. Remove the catheter and replace with an indwelling catheter. C. Allow the bladder to empty completely or up to 1,000 mL of urine. D. Clamp the catheter for thirty minutes and then resume draining.

Correct Answer is C

Explanation

A. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume.

B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage.

C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort.

D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives to 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 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 serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is C

Explanation

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Exhibits What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply.

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

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 mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?