A nurse is caring for a client who is receiving morphine.
Which of the following assessments should the nurse perform first?
Apical heart rate.
Blood pressure.
Respiratory rate.
Level of consciousness.
The Correct Answer is C
Choice A rationale
Assessing the apical heart rate is important but not the first priority when administering morphine. Respiratory rate takes precedence due to the risk of respiratory depression, a common adverse effect of opioids.
Choice B rationale
Monitoring blood pressure is essential, but the first priority is to assess respiratory rate to promptly identify and address any respiratory depression, which is a critical side effect of morphine administration.
Choice C rationale
Respiratory rate must be assessed first because morphine can cause respiratory depression. Early detection of decreased respiratory rate ensures timely intervention and prevention of severe complications related to opioid use.
Choice D rationale
Level of consciousness should be monitored, as morphine can cause sedation. However, the initial priority is to assess respiratory rate to detect any immediate life-threatening respiratory depression caused by the opioid. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Magnesium level of 2.5 mEq/L is slightly above the normal range (1.3 to 2.1 mEq/L) but does not necessitate discontinuation of clozapine, as it does not indicate a serious adverse effect.
Choice B rationale
Potassium level of 5.4 mEq/L is marginally elevated above the normal range (3.5 to 5 mEq/L) but is not a critical concern for discontinuing clozapine, which is more closely monitored for hematologic effects.
Choice C rationale
A WBC count of 2,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). Clozapine can cause agranulocytosis, a severe decrease in white blood cells, necessitating immediate discontinuation.
Choice D rationale
Sodium level of 134 mEq/L is slightly below the normal range (136 to 145 mEq/L) but does not require discontinuation of clozapine. This mild hyponatremia can be monitored and managed without stopping the medication.
Correct Answer is D
Explanation
Choice A rationale
Lactated Ringer's is an isotonic solution containing electrolytes. It is typically used to replace fluid and electrolyte losses and to maintain fluid balance but does not provide a hypotonic environment.
Choice B rationale
0.9% sodium chloride, also known as normal saline, is an isotonic solution. It is commonly used for fluid resuscitation and to increase intravascular volume, not suitable for creating a hypotonic effect.
Choice C rationale
3% sodium chloride is a hypertonic solution, which can cause cells to shrink as water is drawn out. It is used to treat severe hyponatremia but does not provide the hypotonic effect required in this case.
Choice D rationale
0.45% sodium chloride is a hypotonic solution. It helps to hydrate cells by allowing water to move into them. It is used to treat conditions that cause cellular dehydration and is appropriate for this prescription.
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