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Exhibits

The charge nurse places a fall precautions sign on the client's door.

Which side effects of morphine could contribute to this client's fall risk? Select all that apply

Orthostatic hypotension

Sedation

Seizures

itching

Nausea

Urinary retention

Euphoria

Answer and Explanation

Correct Answer : A,B,E,F

A. Orthostatic hypotension: Morphine can cause vasodilation and reduce blood pressure, especially when the client moves from lying to standing positions. This drop in blood pressure increases the risk of dizziness and falls, particularly in postoperative patients who may already be weakened.

B. Sedation: Morphine’s central nervous system depressant effects can cause sedation and impaired alertness. Reduced cognitive and motor function from sedation significantly raises the client’s risk of falls by affecting balance and reaction time.

C. Seizures: Seizures are not a common side effect of morphine. While morphine affects the central nervous system, it typically does not provoke seizure activity in most clients, so it is less relevant as a direct fall risk factor.

D. Itching: Morphine commonly causes itching due to histamine release but this side effect does not directly increase fall risk. Itching may cause discomfort but is unlikely to impair balance or cognition.

E. Nausea: Morphine-induced nausea can cause dizziness, weakness, and dehydration, which contribute indirectly to fall risk. Nausea may also reduce food and fluid intake, worsening the client’s overall stability.

F. Urinary retention: Urinary retention can lead to urgency and frequent bathroom trips, increasing the likelihood of falls, especially if the client rushes or moves unassisted. Postoperative patients with retention are at higher risk of falls during toileting.

G. Euphoria: Euphoria is a central nervous system effect of morphine but does not typically impair balance or motor control to a degree that increases fall risk. It may affect mood but is not directly linked to falls.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Give sucralfate on an empty stomach: Sucralfate forms a protective barrier over ulcers by binding to damaged mucosa. Administering it on an empty stomach, typically 1 hour before meals and at bedtime, maximizes its effectiveness by allowing it to coat the ulcerated area without interference from food.

B. Administer sucralfate once a day, preferably at bedtime: Sucralfate is usually given multiple times a day (often four times daily) to maintain continuous protection of the gastric lining. Once-daily dosing is insufficient to provide adequate ulcer coverage and healing.

C. Assess for secondary Candida infection: Sucralfate itself does not commonly predispose to fungal infections. Routine assessment for Candida is not a priority in clients receiving sucralfate.

D. Monitor for electrolyte imbalance: Sucralfate generally does not affect electrolyte balance directly. Electrolyte monitoring is more critical with other ulcer medications like proton pump inhibitors or diuretics, rather than sucralfate administration.

A. Refer the client to the healthcare provider at the clinic to obtain a medication prescription. B. Explain to the client that antibiotics are not useful in treating viral infections such as influenza. C. Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms. D. Advise the client that once symptoms occur it is too late to receive an influenza vaccination.

Correct Answer is A

Explanation

A. Refer the client to the healthcare provider at the clinic to obtain a medication prescription: Oseltamivir is an antiviral medication that requires a prescription. Early initiation, ideally within 48 hours of symptom onset, can reduce the severity and duration of influenza, making prompt referral essential.

B. Explain to the client that antibiotics are not useful in treating viral infections such as influenza: While this is true, it does not address the client’s question about oseltamivir, which is an antiviral, not an antibiotic.

C. Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms: Over-the-counter meds can help alleviate symptoms but do not treat the viral infection itself. Oseltamivir can shorten illness duration if started early, so OTC meds alone may not be sufficient.

D. Advise the client that once symptoms occur it is too late to receive an influenza vaccination: Vaccination is preventative and should be given before exposure or illness onset. However, this response does not address treatment options once symptoms have started.

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Exhibits The charge nurse places a fall precautions sign on the client's door. Which side effects of morphine could contribute to this client's fall risk? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to administer sucralfate to a client with peptic ulcer disease. Which action should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

A client with symptoms of influenza that started the previous day, asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

Correct Answer is A

Explanation

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Exhibits

The charge nurse places a fall precautions sign on the client's door.

Which side effects of morphine could contribute to this client's fall risk? Select all that apply