The client is a 42-year-old female who had a right above-the- knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What actions should the nurse take to assure safety morphine administration? Select all that apply.

Suction the client to clear the airway

Restrain the client with soft restraints

Perform a 12-lead electrocardiogram

Have a manual resuscitation bag at the bedside

Ask the client about other medications she takes

Take an initial respiratory rate

Answer and Explanation

Correct Answer : E,F

A. Suctioning the client to clear the airway is not directly related to the administration of morphine and is typically not a routine precaution unless the patient has a specific need.
B. Using soft restraints is not a standard safety measure for morphine administration and could be considered if the patient has a history of confusion or agitation, but there is no such indication in this scenario.
C. Performing a 12-lead electrocardiogram is not a standard procedure for ensuring the safe administration of morphine and is usually done for cardiac assessment.
D. Having a manual resuscitation bag at the bedside is a good practice in case of an emergency but is not specific to morphine administration safety.
E. Asking the client about other medications she takes is crucial to prevent drug interactions, as morphine can interact with many medications, potentially leading to adverse effects.
F. Taking an initial respiratory rate is important because morphine can cause respiratory depression, and it is essential to have a baseline to monitor for any changes after administration.

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Free Nursing Study Resources

Correct Answer is ["8"]

Explanation

Given:

IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline.

The prescribed rate is 8 units/hr.

First, we find out how many units are present in 1 mL of the IV solution: 100 units / 100 mL = 1 unit / 1 mL

Now, since the prescribed rate is 8 units/hr, we need to infuse 8 mL/hr of the IV solution to deliver 8 units of insulin per hour.

So, the nurse should program the infusion pump to deliver 8 mL/hr.

A. Remove the catheter and palpate the client's bladder for residual distention. B. Remove the catheter and replace with an indwelling catheter. C. Allow the bladder to empty completely or up to 1,000 mL of urine. D. Clamp the catheter for thirty minutes and then resume draining.

Correct Answer is C

Explanation

A. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume.

B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage.

C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort.

D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes regular insulin 8 units/hr intravenously (IV). The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

Correct Answer is ["8"]

Explanation

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is C

Explanation

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