A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?

Mostly cloudy

Apical heart rate

Blood pressure

Respiratory rate

Level of consciousness

Answer and Explanation

The Correct Answer is D

A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.

B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.

C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.

D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.

E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.

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Correct Answer is A

Explanation

A. Nitrofurantoin can cause brown-colored urine due to its pigment, and clients should be informed to report this as a common side effect and not a cause for alarm.

B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.

C. Nitrofurantoin should not be crushed, as it can affect the medication's absorption and effectiveness.

D. A cough is not a typical side effect of nitrofurantoin; however, if the client develops a cough, it could be a sign of a serious side effect, and they should notify the provider.

A. Mostly cloudy B. Constipation C. Dry mouth D. Daytime drowsiness E. Muscle stiffness

Correct Answer is A

Explanation

A. Mostly cloudy: This is an unclear statement. It is not related to a physical manifestation that would result from haloperidol overdose.

B. Constipation: Although haloperidol can cause constipation as a side effect, it is not the most urgent concern. Other manifestations are more immediately life-threatening.

C. Dry mouth: Dry mouth is a common side effect of antipsychotics, but it is not life-threatening and would not be the priority assessment in the case of a medication overdose.

D. Daytime drowsiness: Sedation is a known side effect of haloperidol, but it is not the priority in this scenario where an overdose occurred.

E. Muscle stiffness: Muscle stiffness may indicate extrapyramidal symptoms (EPS) or neuroleptic malignant syndrome (NMS), both of which are serious and potentially life-threatening side effects of haloperidol, especially in cases of overdose. Assessing for these symptoms is the priority.

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A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for nitrofurantoin. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who has a prescription for haloperidol 0.5 mg PO three times daily. The medication administration record shows that the client received 5 mg per dose on the previous day. Which of the following manifestations is the nurse's priority to assess?

Correct Answer is A

Explanation

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