The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?
Asking for nausea
Evaluating for sacral redness
Checking the respiratory rate
Auscultating bowel sounds
The Correct Answer is C
Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.
By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should inform the client that a common side effect of Lisinopril, an ACE inhibitor, is a chronic dry cough. ACE inhibitors can cause irritation in the respiratory tract, leading to a persistent cough. It is important for the client to be aware of this side effect and report it to their healthcare provider if it becomes bothersome.
Correct Answer is ["A","B","E"]
Explanation
Small bowel obstruction can lead to the accumulation of gastric contents above the obstruction, causing vomiting.
Obstruction of the small bowel can result in crampy, colicky abdominal pain and abdominal distention.
Electrolyte imbalances, such as hypokalemia (low potassium), can occur due to vomiting and inadequate intake in cases of small bowel obstruction.
The following finding is not directly associated with small bowel obstruction:
Pain relief after eating is more commonly associated with peptic ulcer disease, not small bowel obstruction.
While blood in the stool can be seen in some cases of bowel obstruction, it is more commonly associated with lower gastrointestinal bleeding or other conditions affecting the colon, rather than small bowel obstruction.
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