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 D
Explanation
Choice A rationale
Respiratory rate of 24/min indicates possible respiratory distress but is not a common adverse effect of propranolol, which typically affects heart rate and blood pressure.
Choice B rationale
An oral temperature of 38.9° C (102°F) suggests fever, which is not a known adverse effect of propranolol. Common side effects are bradycardia, hypotension, and fatigue.
Choice C rationale
Blood pressure of 118/78 mm Hg is within normal range (90/60 to 120/80 mm Hg) and is not an adverse effect of propranolol, which usually lowers blood pressure.
Choice D rationale
Apical pulse of 50/min indicates bradycardia, a common adverse effect of propranolol, which reduces heart rate by blocking beta-adrenergic receptors.
Correct Answer is D
Explanation
Choice A rationale
Brown-colored urine is a common side effect of nitrofurantoin and is typically not harmful. It occurs due to the drug being metabolized and excreted in the urine, which can alter its color.
Choice B rationale
Nitrofurantoin is an antibiotic used to treat urinary tract infections. It is not indicated for relief of peripheral nerve pain, which is typically managed with medications like gabapentin or pregabalin.
Choice C rationale
Crushing nitrofurantoin tablets can alter the medication’s absorption and effectiveness. It is recommended to swallow the tablets whole to ensure proper release and action of the drug in the body.
Choice D rationale
Developing a cough while taking nitrofurantoin could indicate a hypersensitivity reaction or a serious pulmonary condition like interstitial lung disease. Reporting this symptom is crucial for timely evaluation and intervention.
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