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","B","C","E"]
Explanation
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”.The client can point to a position on the line that corresponds to their pain intensity.VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain.Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain.They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia.The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
Correct Answer is A
Explanation
The correct answer is choice A) Respiratory rate: 10 breaths/min.This indicates that the patient may be experiencing respiratory depression, which is a serious adverse effect of buprenorphine and other opioids.
Respiratory depression can lead to hypoxia, brain damage, or death if not treated promptly.
The normal respiratory rate for adults is 12 to 20 breaths/min.
Choice B) Blood pressure: 110/70 mm Hg is wrong because this is within the normal range for adults, which is 90/60 to 120/80 mm Hg.Buprenorphine can cause hypotension as a side effect, but this is not evident in this case.
Choice C) Heart rate: 72 beats/min is wrong because this is also within the normal range for adults, which is 60 to 100 beats/min.Buprenorphine can cause bradycardia as a side effect, but this is not evident in this case.
Choice D) Temperature: 37°C is wrong because this is the normal body temperature for humans.Buprenorphine can cause hyperthermia as a side effect, but this is not evident in this case.
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