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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Correct Answer is C

Explanation

A. When the client has ankle edema Ankle edema may indicate fluid retention, which is common during pregnancy but is not directly related to the assessment of deep tendon reflexes (DTRs).

B. Within the first trimester of pregnancy: Assessing DTRs within the first trimester of pregnancy is not specifically indicated unless there are other signs or symptoms of concern.

C. If the client has an elevated blood pressure: Assessment of DTRs is particularly important if the client has an elevated blood pressure, as it may indicate preeclampsia, a serious pregnancy complication characterized by hypertension and proteinuria.

D. During admission to labor and delivery: While assessment of DTRs may be included in the admission assessment to labor and delivery, it is particularly important to assess DTRs if the client has an elevated blood pressure, as it may indicate preeclampsia.

A. Add egg allergy to client's identification arm band. B. Ask the client to describe her reaction to milk and eggs C. Enter new allergy information in the client's electronic medical record. D. Eliminate the chicken selections from the client's menu. E. Notify the dietary department of the client's egg intolerance

Correct Answer is ["A","B","C","E"]

Explanation

A. It is important to add the egg allergy to the client's identification arm band to alert all healthcare providers of the allergy, ensuring the safety of the client by preventing accidental exposure.

B. Asking the client to describe her reactions can help the healthcare team understand the severity of the allergies and tailor care appropriately.

C. Entering the new allergy information into the client's electronic medical record is crucial for maintaining an up-to-date health record and ensuring that all team members are aware of the allergies.

D. Eliminating chicken from the client's menu is not necessary unless the client has specifically stated an allergy to chicken. Lactose intolerance and egg allergy do not automatically imply a chicken allergy.

E. Notifying the dietary department of the client's egg intolerance is essential to prevent the inclusion of eggs in the client's meals, which could lead to an allergic reaction.

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Naxlex Comprehensive Predictor Exams

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

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 dietitian with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

A client with obstructive sleep apnea (OSA ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dl (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

After receiving report, the nurse can most safely plan to assess which client last?