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 C

Explanation

A. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure.
B. Bacterial meningitis is transmitted through hematogenous route and airborne precautions are not always necessary.
C. Clients with meningitis may be sensitive to light, dimming the lights should be implemented to increase comfort by reducing stimuli.
D. Encourage frequent ambulation is not appropriate for bacterial

A. Apply a cold compress to the suprapubic area. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Encourage the client to urinate every 2 hr.

Correct Answer is C

Explanation

A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.

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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?

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Explanation

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Explanation

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