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 D
Explanation
Rationale:
A. This statement is incorrect because the client should remove contact lenses before administering brimonidine and wait at least 15 minutes before reinserting them to ensure proper absorption and avoid irritation.
B. While some mild irritation can occur, it is not a desired effect and should not be expected; the nurse should clarify what level of irritation is considered normal.
C. This statement is incorrect as brimonidine is typically a long-term treatment for glaucoma, and clients should not stop using it without consulting their provider.
D. This statement is correct; brimonidine can cause changes in eye color, particularly in individuals with lighter colored eyes, and the client should be informed about this possibility.
Correct Answer is B
Explanation
Rationale:
A. "Cloudy" is not a medication and does not address any adverse effects related to topotecan.
B. Granisetron is an antiemetic medication used to prevent nausea and vomiting, which are common adverse effects of topotecan.
C. Insulin lispro is a rapid-acting insulin used to control blood sugar levels and does not relate to the adverse effects of topotecan.
D. Docusate sodium is a stool softener used to prevent constipation, but it does not specifically address the nausea and vomiting associated with chemotherapy.
E. Prednisone is a corticosteroid that may be used for other indications but is not primarily indicated for treating the nausea and vomiting caused by topotecan.