The nurse is caring for a patient who had abdominal surgery yesterday and is receiving morphine through patient controlled analgesia (PCA). What action by the nurse is a priority?
Asking for nausea
Evaluating for sacral redness
Checking the respiratory rate
Auscultating bowel sounds
The Correct Answer is C
Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.
By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Acute adrenal insufficiency, also known as adrenal crisis, is characterized by low levels of adrenal hormones, particularly cortisol. One of the primary manifestations of adrenal insufficiency is electrolyte imbalance, specifically hyponatremia (low sodium) and hyperkalemia (high potassium). Inadequate cortisol levels can lead to impaired sodium reabsorption in the kidneys, resulting in sodium loss and low serum sodium levels.
When the patient receives appropriate therapies for acute adrenal insufficiency, such as administration of glucocorticoids (e.g., hydrocortisone), the cortisol levels begin to normalize. As a result, the impaired sodium reabsorption improves, leading to an increase in serum sodium levels.
Correct Answer is A
Explanation
Glipizide is an oral antidiabetic medication commonly prescribed to manage type 2 diabetes. It works by stimulating the release of insulin from the pancreas, which helps lower blood glucose levels. However, there is a risk of hypoglycemia (low blood sugar) with the use of Glipizide.
It is crucial for the client to be aware of the signs and symptoms of hypoglycemia so that they can take appropriate action if their blood sugar drops too low. These symptoms may include sweating, trembling, dizziness, confusion, weakness, and hunger. By recognizing these signs, the client can promptly address hypoglycemia by consuming a source of fast-acting glucose, such as fruit juice or glucose tablets, as instructed by their healthcare provider.
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