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 A
Explanation
Rationale:
A. Increase calcium intake: Leuprolide can cause a decrease in bone density, increasing the risk of osteoporosis. Therefore, the nurse should advise the client to increase calcium and vitamin D intake to help maintain bone health.
B. Keep the solution cold for administration: Leuprolide should be stored at room temperature, not refrigerated, for subcutaneous administration.
C. This medication can cause low blood glucose levels: Leuprolide does not typically affect blood glucose levels. However, it can cause other endocrine-related side effects, such as hot flashes and reduced libido.
D. This medication can cause constipation: Constipation is not a common side effect of leuprolide. Instead, leuprolide is more likely to cause side effects such as hot flashes and loss of bone density.
Correct Answer is B
Explanation
Rationale:
A. Nitrates: Nitrates are primarily used to manage angina or heart conditions and are unrelated to acetazolamide or its potential for allergic reactions.
B. Sulfa-based medications: Acetazolamide is a carbonic anhydrase inhibitor that contains sulfonamide groups. Clients with a sulfa allergy may experience a cross-sensitivity reaction, so it's important to confirm any history of sulfa allergies before administration.
C. Mostly cloudy: This option does not relate to any medication classification and is incorrect.
D. Antilipemic agents: Antilipemics are used to lower cholesterol and are not related to acetazolamide or its potential for allergic reactions.
E. Proton pump inhibitors: Proton pump inhibitors are used to reduce stomach acid and do not have a known cross-sensitivity with acetazolamide.