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 ["0.2"]

Explanation

750mcg=2.4ml 60mcg=602.4/750

=0.192ml

Rounded off to the nearest tenth= 0.2ml

A. Place an indwelling urinary catheter and measure strict intake and output. B. Keep the bed in the lowest position and initiate seizure and fall precautions. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Maintain elevated positioning of the dependent joints on the affected side.

Correct Answer is C

Explanation

A. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.

B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.

C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a dose of teriparatide for a patient. The medication is labeled as “750 mcg/2.4 mL”. How many mL should the nurse administer to deliver a dose of 60 mcg. (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.2"]

Explanation

The nurse is caring for a client who arrives at 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 C

Explanation

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