A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Bowel sounds

Respiratory rate

Urine output

Pupil reaction

Answer and Explanation

The Correct Answer is B

A. While morphine can affect bowel sounds by causing constipation, this is not the priority assessment before administration.
B. Respiratory rate is the priority assessment because morphine can cause respiratory depression, which is a life-threatening side effect.
C. Urine output is important to monitor for overall kidney function and hydration status but is not the immediate priority before administering morphine.
D. Pupil reaction can indicate opioid effects, but monitoring respiratory status is more critical.

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Correct Answer is A

Explanation

A. Vomiting is a common early sign of lithium toxicity and indicates the need for immediate medical evaluation.
B. Increased flatulence is not a recognized symptom of lithium toxicity.
C. While headaches can be a side effect, they are not a specific indicator of lithium toxicity.
D. Loss of appetite can be a symptom of many conditions and is not a specific sign of lithium toxicity.

A. "I gave my client a bolus dose of morphine when I initiated the PCA pump." B. "I noted that my client pushed the PCA button six times in the last hour, and the PCA lockout is set for 10 minutes." C. "I told the client's family that they must not push the PCA button for the client." D. "I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."

Correct Answer is D

Explanation

A. Administering a bolus dose of morphine at PCA initiation is a common practice.
B. Monitoring the frequency of button presses and understanding the lockout period is appropriate.
C. Educating the family not to push the PCA button is correct and ensures patient safety.
D. Discarding the remaining medication should be witnessed and documented correctly, but the process should follow the institution’s protocol, and witnessing should have been done before discarding, not after.

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A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

Correct Answer is D

Explanation

A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reactions to this medication?

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

A nurse is assessing a client who has been taking sertraline for 2 weeks. The nurse should identify which of the following findings as an indication that the medication is effective?

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?