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. A respiratory rate of 24/min is elevated and may suggest respiratory distress, but it is not a specific adverse effect of propranolol.
B. An oral temperature of 38.9° C (102° F) indicates fever, which is not a typical adverse effect of propranolol.
C. A blood pressure of 118/78 mm Hg is within normal limits and does not indicate an adverse effect of propranolol, which is often used to manage hypertension.
D. An apical pulse of 50/min indicates bradycardia, a known adverse effect of propranolol, which can occur due to its action on the heart rate.
Correct Answer is B
Explanation
Rationale:
A. A decrease in the amount of gastric acid production: Alosetron is not used to decrease gastric acid production. This effect is more associated with medications such as proton pump inhibitors or H2 blockers.
B. A decrease in the frequency of defecation: Alosetron is used to treat irritable bowel syndrome with diarrhea (IBS-D) by reducing bowel movement frequency and improving stool consistency.
C. An increase in gastric motility: Alosetron works by decreasing intestinal motility, which helps reduce diarrhea, not by increasing it.
D. An increase in the absorption of water into the intestine: Alosetron does not specifically increase water absorption into the intestine. Its primary effect is slowing intestinal transit to reduce diarrhea.