A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
Urinary retention
Vomiting
Respiratory rate
Level of consciousness
The Correct Answer is C
A. Urinary retention: While urinary retention can be a side effect of meperidine and other opioids, it is not the priority assessment before administering the medication. Urinary retention is a concern but is not immediately life-threatening compared to other potential side effects of opioids, such as respiratory depression. Assessing urinary retention is important, but it is not the primary concern in this situation.
B. Vomiting: Vomiting can also be a side effect of opioids, including meperidine. While it is essential to assess for vomiting and its potential impact on the client's overall condition, it is not the priority assessment before administering the medication. Vomiting can be managed, and the nurse should address it as needed. However, the priority assessment is one that can affect the client's immediate safety and well-being, such as respiratory rate and potential respiratory depression.
C. Respiratory rate: This is the correct answer. The priority assessment before administering meperidine is the client's respiratory rate. Opioids can cause respiratory depression, leading to reduced breathing and inadequate ventilation. Monitoring the respiratory rate allows the nurse to detect any signs of respiratory distress or inadequate breathing, enabling them to intervene promptly to prevent serious complications.
D. Level of consciousness: While assessing the client's level of consciousness is essential for overall assessment and monitoring, it is not the priority assessment before administering meperidine. Respiratory depression due to opioid use can occur even when the client is conscious. However, if respiratory depression occurs, it can lead to a decrease in consciousness and potentially unconsciousness, making the assessment of respiratory rate more critical to prevent such complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When caring for a client receiving heparin by continuous IV infusion for the treatment of venous thrombosis, the nurse should monitor the client's aPTT (Activated Partial Thromboplastin Time) to titrate the heparin dose.
Heparin is an anticoagulant medication used to prevent and treat blood clots. The aPTT is a coagulation test that measures the time it takes for the blood to clot when a specific activator is added. Monitoring the aPTT is a standard method for assessing the anticoagulant effect of heparin and ensuring that the client's blood remains within the desired therapeutic range.
The therapeutic range for aPTT while on heparin therapy varies depending on the indication and the client's condition but is generally maintained at a level that prolongs the clotting time enough to prevent and treat thrombosis while avoiding excessive bleeding risk.
Let's go through the other options:
A. Platelet function assay: While monitoring platelet function is essential for assessing overall hemostasis and platelet function, it is not specifically used for titrating heparin doses. Platelet function assays are more commonly used to assess the function of platelets in the context of platelet disorders or antiplatelet medication therapy.
C. INR (International Normalized Ratio): The INR is used to monitor the effect of vitamin K antagonist anticoagulants, such as warfarin, and is not the appropriate test for monitoring heparin therapy.
D. Amylase: Amylase is an enzyme produced by the pancreas and salivary glands and is not relevant for monitoring heparin therapy. Elevated amylase levels are typically associated with pancreatitis and not related to heparin treatment.
Correct Answer is A
Explanation
Furosemide is a loop diuretic commonly used to treat fluid volume excess by promoting diuresis. One of the expected outcomes of furosemide administration is an increased urinary output as excess fluid is eliminated from the body. Therefore, if the medication has been effective, the nurse would expect to see an increased urinary output as a result of the diuretic effect.
Increased respiratory rate (B) is not an expected outcome of furosemide administration. It may occur in some cases due to increased fluid elimination and potential electrolyte imbalances, but it is not the primary indicator of the medication's effectiveness.
Decreased blood pressure (C) is a possible outcome of furosemide administration due to the diuretic effect and subsequent reduction in fluid volume. However, it is not the most specific indicator of the medication's effectiveness in this case.
Increased pulse (D) is not a typical finding associated with the effectiveness of furosemide. In fact, furosemide can sometimes cause a decrease in heart rate due to its impact on fluid and electrolyte balance.
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