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. Dyspepsia: While dyspepsia can be uncomfortable, it is not a critical finding that requires immediate reporting to the provider. It may be a common side effect of statins but typically does not warrant urgent intervention.
B. Elevated creatine kinase: An elevated creatine kinase level can indicate muscle damage, which is a serious side effect associated with rosuvastatin and other statins. This finding requires immediate reporting to prevent complications such as rhabdomyolysis.
C. Headache: A headache may occur with many medications and does not usually require immediate reporting unless it is severe or persistent.
D. Mostly cloudy: This option does not pertain to any specific clinical finding or symptom and is therefore not relevant to the question.
E. Decreased HDL cholesterol: While low HDL cholesterol can be a concern, it is not as urgent as elevated creatine kinase levels and typically does not require immediate action.
Correct Answer is C
Explanation
Rationale:
A. Bradycardia: Albuterol can cause an increase in heart rate (tachycardia) as a common side effect, not a decrease in heart rate, so bradycardia would not be expected.
B. Wheezing: Albuterol is used to relieve wheezing by causing bronchodilation, so continued wheezing after administration would suggest ineffective treatment rather than being an expected finding.
C. Tremors: Tremors are a common side effect of albuterol due to its stimulation of beta-2 receptors in the muscles. This is often seen after nebulizer treatments.
D. Sleepiness: Albuterol generally causes stimulation of the central nervous system, leading to restlessness or nervousness, not sleepiness.