Patient Data
The nurse needs to determine the priority assessment before administering morphine.
Select from Word Choices to complete the sentence.
Before administering morphine, the most important assessment to perform is to check the client's ______________
Temperature
Heart rate
Respiratory rate
Blood pressure
The Correct Answer is C
A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.
B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.
C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.
D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.
B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.
C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.
D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.
E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Complete blood count: A CBC is essential to evaluate hemoglobin and hematocrit levels, which can indicate the severity of blood loss from abdominal trauma. It also helps monitor for anemia or infection risk in this critical setting.
B. Arterial blood gas: An ABG provides information about oxygenation, ventilation, and acid–base balance, which are crucial for a trauma client on mechanical ventilation. It guides adjustments in ventilator settings and assesses for shock-related metabolic acidosis.
C. Type and screen: Given the evidence of internal bleeding and hypotension, a blood transfusion may be necessary. A type and screen ensures blood products can be matched and made available quickly in case of massive transfusion.
D. Coagulation studies: Trauma and massive transfusion can lead to coagulopathy. PT, INR, and aPTT results help guide interventions such as plasma or platelet administration, ensuring proper clotting function during surgery and recovery.
E. Electrolytes: Monitoring electrolytes is important because fluid resuscitation, blood loss, and shock can cause significant imbalances, such as hypokalemia or metabolic derangements, which can complicate management.
F. Blood culture: Blood cultures are obtained when infection or sepsis is suspected. This client’s presentation is acute trauma-related hemorrhage, not infection, so this test is not immediately useful.
G. Urine osmolality: This test is used to evaluate renal concentrating ability and fluid balance, but it is not a priority in acute trauma. Immediate fluid and blood replacement are the focus.
H. Lipid panel: A lipid panel assesses long-term cardiovascular risk, not acute trauma or hemorrhage. It has no role in the immediate plan of care for this client.
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