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. Frequent sputum tests may be needed to monitor the effectiveness of isoniazid, particularly in assessing the resolution of tuberculosis infection.
B. Isoniazid is usually prescribed for a minimum of six months for tuberculosis treatment, not just a month. Thus, stopping after one month is incorrect.
C. Antacids containing aluminum should not be taken concurrently with isoniazid, as they can interfere with the absorption of the medication, reducing its effectiveness.
D. Constipation is not a common side effect of isoniazid. The more frequent side effects include peripheral neuropathy and liver toxicity, making this statement incorrect.
Correct Answer is C
Explanation
Rationale:
A. Muscle rigidity of the extremities: This finding is more indicative of hyperkalemia or severe electrolyte imbalances but is not a common symptom of hypokalemia.
B. Bounding radial pulses: This finding is more associated with hypervolemia or hyperkalemia, not with hypokalemia caused by furosemide.
C. Depressed deep tendon reflexes: This is the correct response, as low potassium levels (hypokalemia) can lead to diminished reflexes due to its role in neuromuscular function.
D. Increased bowel motility: This is incorrect, as hypokalemia typically results in decreased bowel motility and may cause constipation rather than increased motility.