A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient?
The patient's respiratory rate
The appearance of the incision
The date of the patient's last bowel movement
The patient's pulse rate
The Correct Answer is A
A. The patient's respiratory rate: Morphine sulfate is an opioid analgesic that can cause
respiratory depression as a side effect. Therefore, assessing the patient's respiratory rate is crucial before administering the medication to ensure it is within normal limits.
B. The appearance of the incision: While assessing the incision is important for overall surgical site assessment, it's not directly related to the administration of morphine sulfate.
C. The date of the patient's last bowel movement: Bowel movements may be impacted by anesthesia and surgery, but they are not directly relevant to assessing the safety of administering morphine sulfate.
D. The patient's pulse rate: Pulse rate is important for overall assessment of the patient's
condition but may not directly indicate the need for or safety of administering morphine sulfate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assessment of the patient's pain level: While pain assessment is important, the patient's lethargy and shallow respirations indicate a potential opioid overdose, which takes priority.
B. Close observation of signs of opioid tolerance: The patient's symptoms are indicative of opioid overdose, not tolerance.
C. Immediate intubation and artificial ventilation: While respiratory support may eventually be necessary if the patient's condition deteriorates further, administering naloxone to reverse the opioid effects is the initial priority.
D. Administration of naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors, which can rapidly restore normal respiratory function and
consciousness in patients experiencing opioid-induced respiratory depression.
Correct Answer is ["50"]
Explanation
Gtt/min= Volume per hour× Drop factor/ Time in minutes per hour Given:
Volume per hour = 150 mL Drop factor = 20 gtt/mL
Time in minutes per hour = 60 minutes Gtt/min= 150mL/hr×20gtt/mL/60min/hr Gtt/min=50
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min
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