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.

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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.

A. Conversion of the client's PPD test from negative to positive B. History of intravenous drug abuse C. Current diagnosis of hepatitis B D. Length of time of exposure to tuberculosis

Correct Answer is C

Explanation

A. Conversion of the PPD test from negative to positive indicates exposure to tuberculosis but does not contraindicate the administration of isoniazid. It may actually indicate the need for prophylactic treatment.

B. A history of intravenous drug abuse is not directly related to the administration of isoniazid. However, it may be important for assessing risk factors for tuberculosis transmission and adherence to treatment.

C. Isoniazid can cause hepatotoxicity, so it is essential to assess for pre-existing liver conditions such as hepatitis B before administering the medication. Hepatitis B may increase the risk of liver damage associated with isoniazid.

D. The length of time of exposure to tuberculosis is important for assessing the risk of infection and determining the need for prophylactic treatment but does not impact the administration of isoniazid.

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Naxlex Comprehensive Predictor Exams

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

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

Explanation

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is C

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

A client with obstructive sleep apnea (OSA ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

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?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

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

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

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO to Which on should the nurse include in this client's teaching plan? (Select all that apply)

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?