The nurse is caring for a client receiving morphine through a Patient Controlled Analgesia Pump (PCA Pump). The nurse knows that important considerations for this treatment include: SELECT ALL THAT APPLY

Assessing mental status and level of consciousness

Assessing urine output frequently

Monitoring potassium levels

Teaching the family that only the client can press the button for pain medication

Ensuring there is an order for Naloxone in case of overdose

Assessing CO2 levels

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A reason: This statement is true. Assessing mental status and level of consciousness is an important consideration for this treatment, as morphine can cause sedation, confusion, and respiratory depression. The nurse should monitor the client's orientation, alertness, and responsiveness, and use a sedation scale to evaluate the degree of sedation.

Choice B reason: This statement is true. Assessing urine output frequently is an important consideration for this treatment, as morphine can cause urinary retention, which can lead to bladder distension, infection, or kidney damage. The nurse should measure the client's urine output and check for signs of bladder fullness or discomfort.

Choice C reason: This statement is false. Monitoring potassium levels is not an important consideration for this treatment, as morphine does not affect the blood potassium level. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Potassium imbalance can be caused by other factors, such as diuretics, vomiting, diarrhea, or acid-base disorders.

Choice D reason: This statement is true. Teaching the family that only the client can press the button for pain medication is an important consideration for this treatment, as PCA Pump allows the client to self-administer a preset dose of morphine within a specified time interval. The family should not press the button for the client, as this can result in overmedication, overdose, or addiction.

Choice E reason: This statement is true. Ensuring there is an order for Naloxone in case of overdose is an important consideration for this treatment, as Naloxone is an antidote that can reverse the effects of morphine in the event of an overdose. Naloxone can restore the client's breathing, blood pressure, and consciousness, and prevent death.

Choice F reason: This statement is true. Assessing CO2 levels is an important consideration for this treatment, as morphine can cause respiratory depression, which can lead to hypercapnia, or high blood carbon dioxide level. Hypercapnia can cause headache, drowsiness, confusion, and coma. The nurse should monitor the client's respiratory rate, depth, and rhythm, and use a capnograph or a blood gas analysis to measure the CO2 level.

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Correct Answer is C

Explanation

Choice A reason: This statement is false. The patient’s radial pulse is 105 beats/min is not the assessment data that will require the most rapid response by the nurse. A high pulse rate can indicate dehydration, anxiety, or fever, but it is not a life-threatening condition.

Choice B reason: This statement is false. There is sediment and blood in the patient’s urine is not the assessment data that will require the most rapid response by the nurse. Sediment and blood in the urine can indicate kidney damage, infection, or trauma, but they are not an immediate complication of hyponatremia.

Choice C reason: This statement is true. There are crackles throughout both lung fields is the assessment data that will require the most rapid response by the nurse. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli, which can impair gas exchange and cause respiratory distress. Crackles can be a sign of pulmonary edema, a serious complication of hyponatremia that requires prompt treatment.

Choice D reason: This statement is false. The blood pressure increases from 120/80 to 142/94 mm Hg is not the assessment data that will require the most rapid response by the nurse. A high blood pressure can indicate fluid overload, stress, or pain, but it is not a critical condition.

A. Help the vaccination be more effective B. Prevent hypoglycemia from the stress of the injection C. Provide additional calories to prevent malnourishment D. Soothe and distract the infant from pain

Correct Answer is D

Explanation

Choice A reason: This statement is false. A sugar-water pacifier does not help the vaccination be more effective. Vaccinations are effective because they stimulate the immune system to produce antibodies against a specific disease.

Choice B reason: This statement is false. A sugar-water pacifier does not prevent hypoglycemia from the stress of the injection. Hypoglycemia is a condition where the blood sugar level is too low, which can cause symptoms such as sweating, trembling, confusion, or seizures. A sugar-water pacifier does not provide enough glucose to prevent hypoglycemia.

Choice C reason: This statement is false. A sugar-water pacifier does not provide additional calories to prevent malnourishment. Malnourishment is a condition where the body does not get enough nutrients, such as protein, vitamins, and minerals, to function properly. A sugar-water pacifier does not provide enough nutrients to prevent malnourishment.

Choice D reason: This statement is true. A sugar-water pacifier soothes and distracts the infant from pain. Sugar-water has a sweet taste that activates the endorphin system, which reduces pain perception. A pacifier also provides oral stimulation and comfort, which distracts the infant from the pain of the injection.

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The nurse is caring for a client receiving morphine through a Patient Controlled Analgesia Pump (PCA Pump). The nurse knows that important considerations for this treatment include: SELECT ALL THAT APPLY

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Naxlex Comprehensive Predictor Exams

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

Correct Answer is C

Explanation

A nursing student sees the nurse dip a pacifier in a sugar-water solution for an infant before administering an intramuscular injection. The nursing student asks why the nurse provided this sugar-water pacifier. The nurse’s appropriate response is: This will:

Correct Answer is D

Explanation

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