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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. The presence of clear, pale red liquid drainage from the rectal tube suggests possible bleeding or other issues that need prompt assessment, making this client a priority.

B. Dark red drainage on a postoperative dressing could indicate bleeding, which requires immediate attention to assess the extent of bleeding and intervene accordingly.

C. Clients with compressed Jackson-Pratt drains may not have adequate drainage, potentially leading to complications such as hematoma or infection if the drain becomes obstructed.

However, since the bulb is compressed, indicating no active drainage, this client can be assessed later.

D. A distended abdomen with no drainage from the nasogastric tube could indicate a bowel obstruction or other gastrointestinal issue requiring urgent assessment, making this client a priority for assessment.

A. Yellow-tinged sputum B. Nausea and headache C. Watery diarrhea D. Increased fatigue

Correct Answer is C

Explanation

A. Yellow-tinged sputum is not uncommon in patients with pneumonia and while it should be monitored, it is not typically a sign of an adverse reaction to linezolid.

B. Nausea and headache may occur with many medications and are not specific to linezolid; these symptoms should be reported, but they are not the most critical.

C. Watery diarrhea could indicate a potentially serious condition known as Clostridium difficile- associated diarrhea, which is an important complication to report when a patient is on antibiotics like linezolid.

D. Increased fatigue can be associated with the client's underlying condition of pneumonia and while it should be assessed, it is not the most critical finding to report in relation to linezolid therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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 (DW) 1,000 ml. How many ml/hour should the nurse program the infusion pump? (Enter numerical value only)

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?