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","E"]
Explanation
Rationale:
A. Educating the client about the consequences of not taking valproic acid is essential to ensure they understand the importance of adherence to the medication regimen.
B. Suggesting that the client take the medication with food can help minimize gastrointestinal side effects such as nausea.
C. Documenting the client's refusal in the medication administration record is a critical step to maintain accurate medical records and to inform other healthcare providers.
D. Offering to administer the medication IM is not appropriate, as valproic acid is typically given orally and not via intramuscular injection.
E. Recommending the client ask the provider about an enteric-coated formulation may provide a more tolerable option to reduce gastrointestinal side effects.
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.