Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

A nurse is caring for a client who is receiving morphine. Which of the following assessments should the nurse perform first?

A.

Mostly cloudy

B.

Apical heart rate

C.

Blood pressure

D.

Respiratory rate

E.

Level of consciousness

Answer and Explanation

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.

 


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is C

Explanation

Rationale:

A. Magnesium 2.5 mEq/L: A magnesium level slightly above the normal range does not indicate an immediate need to discontinue clozapine, as this level is not related to the adverse effects of the drug.

B. Potassium 5.4 mEq/L: While elevated potassium levels can pose a health risk, this is not a direct indicator to discontinue clozapine. Potassium levels can be managed with other interventions.

C. WBC 2,500/mm³: Clozapine carries a risk of agranulocytosis, a condition where the white blood cell (WBC) count becomes dangerously low, leading to severe infection risk. A WBC count of 2,500/mm³ is below the normal range and indicates the need to discontinue clozapine immediately.

D. Sodium 134 mEq/L: A slightly low sodium level is not typically related to clozapine use and does not warrant discontinuation of the medication.

Correct Answer is C

Explanation

Rationale:

A. Applying a warming blanket is not appropriate and may worsen the client’s reaction to the infusion. It does not help prevent infusion-related reactions.

B. Infusing amphotericin B deoxycholate over 1 hour is too fast; the medication should be infused over 2-6 hours to reduce the risk of adverse effects.

C. Administering diphenhydramine prior to administration is recommended to help prevent infusion-related reactions, such as fever and chills, which the client experienced during previous infusions.

D. Monitoring vital signs once per hour is inadequate; vital signs should be monitored more frequently during and immediately after the infusion to promptly identify and manage any adverse reactions.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.