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, B, C, D, E
Explanation
Rationale:
- Administering albuterol first is crucial because it is a bronchodilator that will help open the airways before administering the anti-inflammatory fluticasone.
- The client should rest for 1 minute between puffs of albuterol to allow for the medication to take effect.
- After taking the second puff of albuterol, a longer rest of 5 minutes allows the client to experience the full effects of the bronchodilator.
- Finally, administering fluticasone afterward will help reduce inflammation in the airways, maximizing the benefit of both medications.
Correct Answer is B
Explanation
Rationale:
A. "I will stop taking this medication when I feel better.": The full course of antibiotics should be completed to ensure the infection is fully treated and to prevent antibiotic resistance. This statement shows a misunderstanding.
B. "This medication can increase my risk of sunburn.": Ciprofloxacin can increase sensitivity to sunlight, making the skin more prone to sunburn. Clients are advised to avoid excessive sun exposure and use sunscreen.
C. "I should take my medication daily in the morning with milk.": Ciprofloxacin should not be taken with dairy products as calcium can interfere with the absorption of the medication, reducing its effectiveness.
D. "I should stop taking my birth control pills while I'm taking this medication.": Ciprofloxacin does not require discontinuation of birth control pills, though clients should be aware of the potential for antibiotic interactions to reduce contraceptive effectiveness.