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.

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Correct Answer is C

Explanation

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

A. Reddish streak proximal to the insertion site B. Skin is pale and taut C. The vein is firm and cord-like D. IV fluid leaking from insertion site E. Warmth at the insertion site

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

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.

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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?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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

Explanation

The nurse is caring for a client with a serum magnesium of 2.9 mEq/L. The nurse should anticipate a prescription from the primary healthcare provider for what treatment?

The illustration reflects a client's upper extremity while the nurse obtains a manual blood pressure. Which electrolyte abnormality is the nurse most likely to see in the client's blood chemistry results?

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?

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?

A 28-year-old client is admitted to the hospital with severe bleeding from a fractured femur. Which intravenous fluid should the nurse anticipate will be ordered for volume replacement?