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 B
Explanation
Rationale:
A. "Remove the patch for two to four hours daily.": This is incorrect because transdermal nitroglycerin patches should be worn continuously for 24 hours, with a scheduled time to remove them (usually overnight) to prevent tolerance.
B. "Apply a new patch each day after waking up.": This instruction is correct; clients should apply a new patch daily to ensure continuous therapeutic effects while also allowing a break to reduce tolerance.
C. "Cover the patch with plastic wrap.": This is incorrect; covering the patch with plastic wrap can alter the absorption of the medication and is not necessary.
D. "Replace the existing patch with a new patch as soon as anginal pain begins.": This is incorrect; clients should not replace the patch immediately for angina. Instead, they should use sublingual nitroglycerin for immediate relief and follow the prescribed patch schedule.
Correct Answer is A
Explanation
Rationale:
A. Nitrofurantoin can cause brown-colored urine due to its pigment, and clients should be informed to report this as a common side effect and not a cause for alarm.
B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.
C. Nitrofurantoin should not be crushed, as it can affect the medication's absorption and effectiveness.
D. A cough is not a typical side effect of nitrofurantoin; however, if the client develops a cough, it could be a sign of a serious side effect, and they should notify the provider.