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.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Measuring abdominal girth is not specific to suprapubic catheter care. While it may be relevant in certain situations, it does not directly assess the condition of the catheter or its insertion site.

B. Assessing the perineal area is important, but the primary focus for a client with a suprapubic catheter should be on the insertion site itself, as this is where complications such as infection or leakage are most likely to occur.

C. Assessing the insertion site is essential to monitor for any signs of infection, inflammation, or other complications related to the catheter. This assessment helps ensure the catheter is functioning correctly and that no adverse effects are developing.

D. Palpating the flank area is generally not a routine assessment for a client with a suprapubic catheter unless there are specific concerns about kidney function or pain in that area.

A. Moderate amount of foul-smelling lochia. B. Blood pressure of 122/74 mm Hg. C. Oral temperature of 100.2° F (37.9°C). D. White blood count of 19,000/mm3.

Correct Answer is A

Explanation

A. A moderate amount of foul-smelling lochia can indicate an infection, especially if accompanied by other signs such as fever or abdominal pain.
B. Blood pressure within normal range is not indicative of postpartum infection.

C. While an elevated temperature can be a sign of infection, it's not specific enough on its own.

D. A high white blood count can indicate infection, but it's not as specific as the presence of foul-smelling lochia in the postpartum period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Correct Answer is A

Explanation

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

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 observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

A client receives a prescription for norepinephrine 3 mcg/min intravenously (IV). The IV bag is contains norepinephrine 4 mg in dextrose 5% in water (D,W) 1,000 mL. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?