A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?
Mostly cloudy
Apical heart rate
Blood pressure
Respiratory rate
Level of consciousness
The Correct Answer is D
Rationale:
A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.
B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.
C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.
D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.
E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.
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Correct Answer is D
Explanation
Rationale:
A. This statement is incorrect because the client should remove contact lenses before administering brimonidine and wait at least 15 minutes before reinserting them to ensure proper absorption and avoid irritation.
B. While some mild irritation can occur, it is not a desired effect and should not be expected; the nurse should clarify what level of irritation is considered normal.
C. This statement is incorrect as brimonidine is typically a long-term treatment for glaucoma, and clients should not stop using it without consulting their provider.
D. This statement is correct; brimonidine can cause changes in eye color, particularly in individuals with lighter colored eyes, and the client should be informed about this possibility.
Correct Answer is D
Explanation
Rationale:
A. Cataracts are not a contraindication for cholinesterase inhibitors like neostigmine.
B. Hypertension is not a direct contraindication for cholinesterase inhibitor therapy, although caution may be exercised depending on the overall health status of the client.
C. Hypothyroidism is not contraindicated for cholinesterase inhibitors; however, it should be managed appropriately.
D. Peptic ulcer disease is a significant contraindication for cholinesterase inhibitors like neostigmine because these medications can increase gastric secretions and motility, potentially exacerbating ulcer conditions and leading to complications.