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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is choice A, B, C, and D.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that has anti-inflammatory, analgesic, and antipyretic effects.It works by inhibiting the synthesis of prostaglandins, which are involved in inflammation, pain, and fever.However, ibuprofen can also cause adverse effects such as gastric irritation, bleeding complications, renal impairment, and hypersensitivity reactions.
Therefore, the nurse should instruct the client to:
• Take ibuprofen with food or milk to prevent gastric irritation.This will reduce the direct contact of the drug with the stomach lining and decrease the risk of ulcers and bleeding.
• Drink at least 2 liters of fluid per day to prevent renal impairment.This will help maintain adequate hydration and renal perfusion and prevent the accumulation of ibuprofen in the kidneys.
• Avoid alcohol and other NSAIDs to prevent bleeding complications.Alcohol and other NSAIDs can increase the risk of gastric bleeding by interfering with the protective effects of prostaglandins on the stomach mucosa.
• Report any signs of hypersensitivity such as rash, itching, or wheezing.These may indicate an allergic reaction to ibuprofen that can be serious or life-threatening.
Choice E is wrong because ibuprofen does not affect blood pressure significantly.However, some other NSAIDs such as celecoxib may increase the risk of cardiovascular events such as thrombosis, myocardial infarction, and stroke.Therefore, clients with hypertension or cardiovascular disease should use NSAIDs with caution and monitor their blood pressure regularly.
Correct Answer is A
Explanation
The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10.This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.
Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.
Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.
Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.
Normal ranges for vital signs are:
• Respiratory rate: 12-20 breaths per minute
• Blood pressure: <120/80 mm Hg
• Pulse oximetry: >95%
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