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 B

Explanation

A. Determining the need for urinary catheterization is within the scope of a registered nurse (RN), as it involves assessment and clinical judgment. A practical nurse (PN) does not independently determine the need for catheterization.
B. Titrating oxygen within prescribed parameters is an appropriate task for a PN, as it involves following provider orders and monitoring the client's response while working under RN supervision.
C. Receiving a postoperative client and conducting the initial assessment requires comprehensive assessment skills, which fall within the RN's scope of practice rather than the PN's.
D. Evaluating and updating plans of care require critical thinking and clinical decision-making, which are responsibilities of the RN. The PN can contribute to care but does not independently evaluate or modify care plans.

A. When the client has ankle edema. B. If the client has an elevated blood pressure. C. During admission to labor and delivery. D. Within the first trimester of pregnancy.

Correct Answer is B

Explanation

A. Assessing DTRs when the client has ankle edema is important, but it is not the most critical time. Ankle edema can be a common occurrence in pregnancy due to increased fluid volume and changes in blood flow.

B. Elevated blood pressure in a pregnant client can be a sign of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Assessing DTRs can help in
detecting hyperreflexia, which is a sign of preeclampsia. Therefore, it is most important to assess DTRs when there is an elevated blood pressure.

C. While assessing DTRs during admission to labor and delivery is a standard procedure to monitor the client's neurological status, it is not as critical as assessing them when there is an elevated blood pressure.

D. Assessing DTRs within the first trimester of pregnancy is not typically a priority unless there are specific clinical indications or concerns. Elevated blood pressure is a more immediate
concern that requires prompt assessment of DTRs

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel Which task should the nurse assign to the PN?

Correct Answer is B

Explanation

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

Correct Answer is B

Explanation

A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

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?

Which environmental factor is most significant when planning care for a client with osteomalacia?

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

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in the level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the take?