A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Emesis of 250 mL

Increased respiratory rate to 26/min

Decreased anxiety

Decreased urinary output

Answer and Explanation

The Correct Answer is C

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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Correct Answer is B

Explanation

B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.

A. Titrate IV fluids to maintain urine output at 75 mL/hr. B. Administer an opioid pain medication, C. Change dressings over the entrance and exit wounds. D. Obtain an ECG

Correct Answer is D

Explanation

D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.

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A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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