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 D

Explanation

A. Assess pupillary response to light hourly: Dopamine administration may cause changes in pupillary response, but it is not the primary concern associated with its administration. Hourly pupillary assessment may not be necessary unless other signs of neurological changes are present.

B. Initiate seizure precautions: While dopamine administration may cause neurological effects, such as agitation or tremors, it is not typically associated with seizure activity. Seizure precautions are not indicated solely due to dopamine infusion.

C. Monitor serum potassium frequently: Dopamine administration can affect potassium levels, but monitoring serum potassium levels frequently may not be necessary unless the client has pre- existing potassium imbalances or is at risk for electrolyte disturbances.

D. Measure urinary output every hour: Dopamine is a vasopressor medication that can increase blood pressure and cardiac output, potentially leading to increased renal perfusion and urinary output. Monitoring urinary output hourly is essential to assess the client's response to dopamine therapy and ensure adequate renal function.

A. Observe insertion site. B. Palpate flank area. C. Measure abdominal girth. D. Assess perineal area.

Correct Answer is A

Explanation

A. Observing the insertion site of the suprapubic catheter is crucial to assess for signs of infection, such as redness, swelling, or drainage. Any abnormalities at the insertion site should be reported promptly for further evaluation and intervention.

B. Palpating the flank area may not be directly related to the care of the suprapubic catheter unless there are specific concerns or symptoms related to the renal system that warrant assessment of the kidneys.

C. While measuring abdominal girth can provide information about abdominal distention or fluid accumulation, it may not directly address the care needs related to the suprapubic catheter unless there are specific concerns related to catheter function or drainage.

D. Assessing the perineal area may be relevant for clients with other types of urinary catheters (e.g., indwelling urethral catheters), but for clients with a suprapubic catheter, the focus is on the site of catheter insertion in the lower abdomen.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is A

Explanation

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

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states. "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive person (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

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?

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings Which action(s) should the charge nurse take? (Select all that apply)

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?