A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Tell the client he can no longer have any more pain medication

Notify the prescribing physician

Administer half the dose of morphine, 2 mg IV

Administer 4 mg of morphine IV as ordered

Answer and Explanation

The Correct Answer is B

A. Tell the client he can no longer have any more pain medication: This is not appropriate. The client’s severe pain needs to be managed, but the current vital signs suggest a need for careful evaluation before administration.
B. Notify the prescribing physician: This is the correct choice. The client's blood pressure and respiratory rate are significantly low, which could be exacerbated by morphine. The physician needs to be informed to reassess pain management and possibly adjust the treatment.
C. Administer half the dose of morphine, 2 mg IV: Given the client's low blood pressure and respiratory rate, any morphine administration could worsen these issues. Adjusting the dose without physician guidance is not appropriate.
D. Administer 4 mg of morphine IV as ordered: Administering the full dose without addressing the client’s low blood pressure and respiratory rate could lead to severe complications.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The client with a serum phosphorus of 4.5 mg/dL that requires assistance with planning their meals: A serum phosphorus level of 4.5 mg/dL is within the normal range, and assistance with meal planning is a lower priority compared to the other situations.
B. The client with a serum magnesium of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes: This client has hypomagnesemia, which can lead to severe complications like seizures or cardiac arrhythmias. Immediate attention is necessary due to the symptoms and the critically low magnesium level.
C. The client with a serum potassium of 5.3 mEq/L and is scheduled for hemodialysis in three hours: This potassium level is slightly elevated, but the scheduled hemodialysis suggests the issue will be addressed soon.
D. The client with a serum sodium of 145 mEq/L who is complaining of a dry mouth and wants a glass of water: A serum sodium of 145 mEq/L is on the high end of normal; the client's dry mouth is concerning but not as urgent as the issues presented by the hypomagnesemia.

A. Serum glucose and a Complete Blood Count B. Arterial blood gas and coagulation tests C. Serum creatinine and a Basic Metabolic Panel D. Chest X-ray and cardiac enzymes

Correct Answer is C

Explanation

A. Serum glucose and a Complete Blood Count: While a complete blood count (CBC) is useful in assessing overall health, serum glucose is less relevant in the context of renal disease. The focus should be on kidney function rather than glucose levels.
B. Arterial blood gas and coagulation tests: Arterial blood gas (ABG) and coagulation tests may be important for other conditions, but they are not specifically targeted to evaluate renal function or related preoperative risks in renal disease.
C. Serum creatinine and a Basic Metabolic Panel: This is the correct choice as serum creatinine is a key marker of kidney function, and a Basic Metabolic Panel (BMP) provides information on electrolyte levels and overall metabolic status, which are crucial in evaluating the impact of renal disease on surgery.
D. Chest X-ray and cardiac enzymes: These tests are more relevant for evaluating cardiac function and lung status rather than directly assessing kidney function, which is the primary concern in the context of renal disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

Correct Answer is B

Explanation

During a preoperative review of systems, the client reveals a history of renal disease. This finding suggests the need for which relevant preoperative diagnostic tests?

Correct Answer is C

Explanation

After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

The client has received IV solution for three (3) days through a 20-gauge IV catheter placed in the left hand. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?

The nurse is reviewing serum laboratory values for a client who is scheduled for surgery tomorrow. Which value requires the nurse to promptly notify the surgeon?

The nurse is educating a client on the use of oral ferrous sulfate. Which statement made by the client requires a need for further education?

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?