A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

The client's blood pressure has been reduced.

The client exhibits diaphoresis.

The client is grimacing.

The client has an elevated heart rate.

Answer and Explanation

The Correct Answer is A

A.   This is the correct answer. Reduction in blood pressure is a common therapeutic response to morphine administration. Morphine acts as a vasodilator, which can lead to decreased blood pressure.
B.   Diaphoresis, or sweating, is not necessarily a therapeutic response to morphine. It may indicate other physiological responses or side effects.
C.   Grimacing suggests pain or discomfort, which is not a therapeutic response but rather an indication that the pain relief from morphine may not be sufficient.
D.   An elevated heart rate is not typically a therapeutic response to morphine and may indicate pain, anxiety, or other factors.

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Correct Answer is D

Explanation

A. Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.
B. Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.
C. Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.
D. Hyperkalemia: Hyperkalemia (elevated potassium levels) is a common electrolyte imbalance seen in the emergent phase of burn injuries due to the release of potassium from damaged cells.
It can lead to cardiac dysrhythmias and other complications if not promptly addressed.

A. Check the client's ability to use the call light. B. Document the client's risk in the medical record. C. Request a referral for physical therapy. D. Place a gait belt in the client's room.

Correct Answer is A

Explanation

A. "Check the client's ability to use the call light." This is the first action to take because ensuring the client can call for assistance if needed is crucial for their safety. If the client has impaired mobility and is at risk for falls, they should be able to summon help easily if they need to move or if assistance is required.

B. "Document the client's risk in the medical record." While documentation is important, ensuring the client can call for help should be prioritized to address immediate safety needs. Documenting the risk can occur after addressing immediate needs.

C. "Request a referral for physical therapy." While physical therapy may be indicated later, the priority is to ensure the client’s immediate safety by confirming they can call for help if needed.

D. "Place a gait belt in the client's room." A gait belt can be useful for assisting with mobility, but the immediate concern is ensuring the client can call for help if they need it, rather than preparing for assistance with mobility.

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A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?

Correct Answer is A

Explanation

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