The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?
Assess the client’s respiratory rate.
Check the client’s allergy history.
Review the client’s medication record.
Verify the dosage with another nurse.
The Correct Answer is B
The correct answer is choice B. Check the client’s allergy history.
This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.
Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.
Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.
Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.
Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.
Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.
Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.
Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The client reports a pain level of 4 on a scale of 0 to 10.This indicates that the PCA pump is effective in reducing the client’s pain, which is the primary symptom of sickle cell crisis.
Choice B is wrong because a respiratory rate of 12 breaths per minute is normal and does not indicate the effectiveness of the PCA pump.
Choice C is wrong because a blood pressure of 140/90 mm Hg is high and may indicate hypertension, which is a complication of sickle cell disease.
Choice D is wrong because a pulse oximetry reading of 95% is normal and does not indicate the effectiveness of the PCA pump.
Normal ranges for vital signs are:
• Respiratory rate: 12-20 breaths per minute
• Blood pressure: <120/80 mm Hg
• Pulse oximetry: >95%
Correct Answer is C
Explanation
The correct answer is choice C.The client should take this medicationregularlyas prescribed to maintain a steady level of analgesia and prevent breakthrough pain.
Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.
Choice A is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.
Choice B is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.
Choice D is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.
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