The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

Assess the client’s respiratory rate.

Check the client’s allergy history.

Review the client’s medication record.

Verify the dosage with another nurse.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Check the client’s allergy history.

This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.

Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.

Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.

Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.

Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.

Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.

Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.

Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.

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Correct Answer is D

Explanation

The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.

Serum bilirubin is a marker of liver function and damage.

A high level of serum bilirubin indicates jaundice, a sign of liver injury.

Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.

Choice B is wrong because serum potassium is not directly affected by acetaminophen.

Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.

Choice C is wrong because serum albumin is a protein that is synthesized by the liver.

Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.

Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.

Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.

Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.

Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.

A. Respiratory rate: 10 breaths/min B. Blood pressure: 110/70 mm Hg C. Heart rate: 72 beats/min D. Temperature: 37°C.

Correct Answer is A

Explanation

The correct answer is choice A) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.

Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.

The normal respiratory rate for adults is 12 to 20 breaths/min.

Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.

Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.

Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.

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The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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