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: Collecting 2 mL of sputum in an emesis basin is not the standard practice as it may not be sterile and could contaminate the specimen.
B: Instructing the client to rinse with an antiseptic mouthwash prior to specimen collection could potentially kill bacteria that need to be cultured, leading to an inaccurate test result.
C: Swabbing the oropharynx with a sterile swab is not the correct method for collecting a sputum specimen for culture and sensitivity, as this method is more suitable for throat cultures.
D: Refrigerating the specimen until the time of transport to the laboratory is the correct action because it preserves the integrity of the sputum sample by slowing down bacterial growth, ensuring that the culture and sensitivity results are accurate. Refrigeration is essential to prevent overgrowth of commensal bacteria that may be present in the specimen.

A. Wheat toast and jelly B. Graham crackers with peanut butter C. Beef barley soup D. Corn tortillas with black beans

Correct Answer is D

Explanation

A. Wheat toast contains gluten, which should be avoided by individuals with celiac disease.

B. Graham crackers typically contain wheat flour, which also contains gluten and should be avoided.
C. Barley contains gluten and should be avoided by individuals with celiac disease.

D. Corn tortillas are typically gluten-free, and black beans are a good source of protein and fiber, making them a suitable option for individuals with celiac disease. It's important to ensure that all food choices are gluten-free to avoid triggering symptoms of celiac disease.

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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

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