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

Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.

Telmisartan has no effect on respiratory rate, urine output or blood glucose.

A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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