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. Diazepam is a benzodiazepine used for anxiety and sedation but is not effective for treating malignant hyperthermia.
B. Dantrolene is the specific antidote for malignant hyperthermia, and the nurse should expect to administer it to help reduce the severe muscle contractions and hypermetabolism associated with this condition.
C. Cyclobenzaprine is a muscle relaxant used for muscle spasms but is not indicated for malignant hyperthermia.
D. Metaxalone is also a muscle relaxant, but like cyclobenzaprine, it is not effective for managing malignant hyperthermia and would not be used in this situation.
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.