Exhibits

Which actions should the nurse take to assure safety during morphine administration? Select all that apply.

Ask the client about other medications she takes.

Suction the client to clear the airway.

Take an initial respiratory rate.

Have a manual resuscitation bag at the bedside.

Perform a 12-lead electrocardiogram.

Restrain the client with soft restraints.

Answer and Explanation

Correct Answer : A,C,D

A. Ask the client about other medications she takes: Knowing the client’s full medication list helps identify potential drug interactions with morphine, such as other CNS depressants, which can increase the risk of respiratory depression and sedation, ensuring safer administration.

B. Suction the client to clear the airway: Suctioning is an intervention used if airway obstruction occurs, but it is not a routine action during morphine administration. It is reactive rather than preventive and should be performed only if the client shows signs of airway compromise.

C. Take an initial respiratory rate: Monitoring respiratory rate before and during morphine infusion is essential because opioids can depress respiration. Baseline respiratory assessment allows early detection of respiratory depression, enabling prompt intervention.

D. Have a manual resuscitation bag at the bedside: A manual resuscitation bag (Ambu bag) must be immediately available to assist ventilation if the client develops respiratory depression or apnea during opioid administration, ensuring rapid emergency response.

E. Perform a 12-lead electrocardiogram: A 12-lead ECG is not routinely indicated solely for morphine administration unless the client has a cardiac condition requiring monitoring. It is not a standard safety measure related to morphine infusion.

F. Restrain the client with soft restraints: Physical restraints are not routinely used for clients receiving morphine unless there is a specific behavioral risk or danger to self or others. Restraints can increase fall risk and are not a standard safety action during opioid administration.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D","dropdown-group-3":"C"}

Explanation

• Decreasing serum sodium levels: Thiazide diuretics reduce blood pressure primarily by promoting the excretion of sodium and water through the kidneys. This decreases blood volume, leading to lower blood pressure by reducing preload and overall circulatory volume.

• Reducing systemic vascular resistance: ACE inhibitors like lisinopril lower blood pressure by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This results in vasodilation and reduced systemic vascular resistance, decreasing the workload on the heart.

• Increasing heart rate: Neither thiazide diuretics nor ACE inhibitors primarily increase heart rate. In fact, reflex tachycardia may occur but is not their main mechanism of blood pressure reduction.

• Reducing stroke volume: ACE inhibitors reduce blood pressure by decreasing both systemic vascular resistance and stroke volume through afterload reduction and mild diuretic effect, which reduces cardiac workload.

• Suppressing the appetite: Neither drug class acts by suppressing appetite. Weight management is important for hypertension control but is unrelated to the direct pharmacologic effects of these medications.

A. Tell the daughter to check with the healthcare provider before providing herbal supplements. B. Remind the client that herbal medications are not regulated by the Food and Drug Administration. C. Remind the daughter that all herbal supplements will not be helpful given the condition of the client. D. Explain that melatonin can interfere with the action of prescribed medications for DM and HF. E. The body builds up a tolerance of melatonin, requiring higher doses to get therapeutic benefits.

Correct Answer is ["A","B","D"]

Explanation

A. Herbal supplements can interact with prescription medications and may have side effects. It is essential to consult the healthcare provider to ensure safety and avoid harmful interactions, especially in clients with complex conditions like diabetes and heart failure.

B. Unlike prescription drugs, herbal supplements are not rigorously tested or regulated for safety, efficacy, or quality. This lack of regulation can lead to variability in product content and unexpected adverse effects.

C. Not all herbal supplements are ineffective; some may provide benefits, though they require careful consideration and medical guidance. Advising that all are unhelpful is inaccurate and dismisses potentially safe options when appropriately supervised.

D. Melatonin may affect blood pressure, blood sugar levels, and interact with heart failure medications, potentially altering their effectiveness or causing adverse effects. Clients should be informed about these risks.

E. The body builds up a tolerance of melatonin, requiring higher doses to get therapeutic benefits: Current evidence does not strongly support tolerance development to melatonin requiring dose escalation. The need for higher doses is not a concern in short-term melatonin use.

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Exhibits Which actions should the nurse take to assure safety during morphine administration? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D","dropdown-group-3":"C"}

Explanation

An older adult client who has type 2 diabetes mellitus (DM) and a history of heart failure (HF) tells the home health nurse that his daughter brought him melatonin to help with sleeping problems. Which information should the nurse provide to the client? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Exhibits Which actions should the nurse take to assure safety during morphine administration? Select all that apply.

A client receives a prescription for IV famotidine. Which finding indicates to the nurse the medication is effective?

A client receives a prescription for methotrexate. Which information provided by the client requires additional instruction by the nurse?

An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving atenolol, furosemide, and enalapril daily. Which assessment(s) should the nurse include in evaluating the effectiveness of the medications? Select all that apply.

Exhibits Click to specify whether the client statements following asthma management education indicate understanding or no understanding. Each row must have one option selected.

The nurse is administering sevelamer during lunch to a client with chronic kidney disease (CKD). The client asks the nurse to bring the medication later. The nurse should describe which action of sevelamer as an explanation for taking it with meals?

Exhibits Review H and P. nurse's notes, flow sheet and orders. Click to mark whether the assessment findings represent the therapeutic result of the bisacodyl administered a non-therapeutic side effect, or an unrelated finding. Each row must have at least one option selected.

A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. Which action should the nurse take?

Exhibits

Which actions should the nurse take to assure safety during morphine administration? Select all that apply.