Patient Data

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

Have a manual resuscitation bag at the bedside.

Suction the client to clear the airway.

Ask the client about other medications she takes.

Perform a 12-lead electrocardiogram.

Restrain the client with soft restraints.

Take an initial respiratory rate.

Answer and Explanation

Correct Answer : A,C,F

A. Have a manual resuscitation bag at the bedside: Because morphine can cause respiratory depression, it is critical to have emergency resuscitation equipment readily available in case the client requires assisted ventilation during an adverse reaction.

B. Suction the client to clear the airway: Routine suctioning is not necessary unless the client has secretions impairing airway patency. It is not a standard precaution for clients receiving IV morphine without signs of airway obstruction.

C. Ask the client about other medications she takes: Morphine can interact dangerously with other medications, particularly sedatives, benzodiazepines, and other central nervous system depressants. Knowing the client’s full medication list helps prevent additive respiratory depression.

D. Perform a 12-lead electrocardiogram: A 12-lead ECG is not a standard requirement when starting morphine therapy unless there are cardiac symptoms. Continuous cardiorespiratory monitoring is already ordered, and that level of cardiac surveillance is sufficient unless new cardiac concerns arise.

E. Restrain the client with soft restraints: Restraints are not appropriate unless the client becomes a danger to herself or others. Administering morphine does not justify the prophylactic use of restraints and would violate ethical care standards.

F. Take an initial respiratory rate: An initial baseline respiratory rate is critical before starting or continuing morphine, as the drug’s main risk is respiratory depression. Ongoing respiratory assessments will be essential during PCA therapy.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Reassure the client that the patch will begin to take effect within a few minutes: Transdermal nitroglycerin provides a slow, continuous release of medication and is not designed to treat acute chest pain. Relying on the patch alone could delay urgently needed relief for ischemic pain.

B. Withhold further doses of nitroglycerin until contacting the healthcare provider: Sublingual nitroglycerin is prescribed specifically for immediate relief of anginal pain. Waiting for provider instructions before addressing active chest pain would not follow standard angina protocols and could endanger the client.

C. Leave the patch in place and administer a PRN dose of sublingual nitroglycerin: In cases of acute chest pain, it is appropriate to maintain the transdermal patch for background therapy and give sublingual nitroglycerin for immediate relief. Sublingual forms act rapidly by dilating coronary arteries and improving blood flow to relieve ischemia.

D. Obtain another transdermal patch and position it on the client's left upper chest: Applying an additional transdermal patch is inappropriate and could result in overdose, severe hypotension and will not provide immediate relief. The onset of action for transdermal nitroglycerin is too slow to address acute chest pain. The focus should be on a rapid-acting form of nitroglycerin.

A. Report the finding to the healthcare provider. B. Check the client's capillary glucose level. C. Advise the client to reduce the medication dose. D. Use a pulse oximeter to assess oxygen saturation.

Correct Answer is A

Explanation

A. Report the finding to the healthcare provider: Yellow discoloration of the skin, or jaundice, suggests possible liver dysfunction, which can occur with acetaminophen toxicity, especially if taken chronically or in high doses. Promptly reporting this finding is crucial so that further evaluation and intervention can be initiated to prevent worsening liver injury.

B. Check the client's capillary glucose level: Although liver dysfunction can eventually affect glucose metabolism, checking a capillary glucose level does not directly address the urgent concern of jaundice and potential hepatotoxicity related to acetaminophen use.

C. Advise the client to reduce the medication dose: Simply advising dose reduction without proper evaluation could delay diagnosis and treatment of potentially serious liver damage. A healthcare provider needs to assess the situation before any medication changes are made.

D. Use a pulse oximeter to assess oxygen saturation: Oxygen saturation monitoring is essential for respiratory or cardiac concerns but does not directly relate to jaundice or liver function. Therefore, it would not be the appropriate first action in this situation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of angina reports the onset of chest pain. The nurse determines that the heart rate is 104 beats/minute and the blood pressure is 138/86 mm Hg. A transdermal nitroglycerin patch was applied 30 minutes ago to the right upper chest. Which action should the nurse take?

Correct Answer is C

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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Patient Data

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