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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.
B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.
C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.
D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.
Correct Answer is B
Explanation
A. 18%: This would be the correct percentage for one leg only.
B. 36%: According to the Rule of Nines in burn assessment, each leg (including the foot) accounts for 18% of the body surface area. Since both lower extremities are affected, it totals 36% body surface area.
C. 4%: This percentage is too low for the described injury.
D. 09%: This would not be enough even for one leg, as each leg is 18%.
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