Nokea
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in
- B. Irregular heart rate of 82 beats/min
- C. Pupils constricted and equal
- D. Respiratory rate of 8breaths/min
Correct Answer: D
Rationale: The assessment finding that suggests the client is experiencing an adverse effect of morphine (Duramorph) is a respiratory rate of 8 breaths/min. Morphine is a potent opioid analgesic that can cause respiratory depression as a side effect. When the respiratory rate decreases significantly, it indicates the potential for compromised breathing, which could progress to respiratory failure. This is a serious adverse effect that requires immediate attention and evaluation by healthcare providers. The client receiving continuous infusion of morphine should be closely monitored for signs of respiratory depression to prevent life-threatening consequences.
You may also like to solve these questions
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The nurse should instruct the patient taking propranolol (Inderal) for hypertension to not stop the medication abruptly. Suddenly stopping propranolol can lead to rebound hypertension and potentially dangerous side effects. It is important for the patient to gradually taper off the medication under the guidance of a healthcare provider to avoid complications. Therefore, advising the patient not to stop the medication abruptly is a crucial instruction to ensure their safety and well-being.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The first priority when a woman with pelvic inflammatory disease complains of lower abdominal pain is to administer antibiotics as ordered. Pelvic inflammatory disease is often caused by a bacterial infection, and prompt treatment with antibiotics is crucial to prevent complications such as infertility or chronic pelvic pain. Addressing the infection promptly is essential in managing the condition and preventing further spread of the infection. Once antibiotic therapy has been initiated, the nurse can proceed with other interventions such as pain management (C), patient education on STDs (D), and assessing pain level (A).
is X linked recessive disorder :
- A. thalassemia
- B. hemophilia
- C. leukemia
- D. sickle anemia
Correct Answer: B
Rationale: Hemophilia is an X-linked recessive disorder where the genes responsible for blood clotting factors are located on the X chromosome. This disorder primarily affects males, as they have only one X chromosome. Females are carriers and can pass the gene on to their sons. Hemophilia results in prolonged bleeding episodes as the blood is unable to clot properly. Thalassemia, leukemia, and sickle cell anemia are not X-linked disorders. Digoxin is a medication used for heart conditions, not related to X-linked disorders.
A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg PO daily. Which finding should the nurse recognize as an adverse effect?
- A. Dysuria
- B. Tachycardia
- C. Leg cramps
- D. Blurred vision
Correct Answer: B
Rationale: Levothyroxine is a synthetic form of thyroid hormone used to treat hypothyroidism. An adverse effect of levothyroxine therapy is the development of tachycardia, which is an abnormally rapid heart rate. This is due to the increased metabolic rate resulting from the thyroid hormone replacement. Dysuria (painful urination), leg cramps, and blurred vision are not typically associated with levothyroxine therapy for hypothyroidism.