Patient Data

Exhibits

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 ______________

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

A. Complete blood count: Zidovudine can cause bone marrow suppression, leading to thrombocytopenia. Pinpoint red spots, or petechiae, are a sign of low platelet count. A CBC is the most relevant test to evaluate for cytopenias and should be reported promptly to the provider.

B. Skin biopsy: A biopsy would help diagnose dermatologic conditions such as rashes, lesions, or malignancies, but petechiae are usually vascular in nature and related to platelet abnormalities.

C. Allergy test: Allergy testing evaluates hypersensitivity to specific allergens but is not relevant here. Petechiae are not typical of allergic reactions; instead, they reflect impaired clotting or low platelets.

D. Electromyography: EMG measures electrical activity in muscles to assess for neuromuscular disorders. It has no connection to the client’s presentation of petechiae and is unrelated to zidovudine’s known adverse effects.