Nokea
A client is receiving morphine sulfate subcutaneously for pain. Because morphine sulfate has been prescribed for this client, which nursing action would be included in the plan of care?
- A. Encourage fluid intake.
- B. Monitor the client's temperature.
- C. Maintain the client in a supine position.
- D. Encourage the client to cough and deep breathe.
Correct Answer: D
Rationale: Morphine sulfate suppresses the cough reflex, which can lead to the retention of secretions in the lungs. Encouraging the client to cough and deep breathe helps prevent pneumonia by clearing the airways of any accumulated secretions. This intervention is crucial in clients receiving morphine sulfate to maintain optimal respiratory function.
You may also like to solve these questions
A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?
- A. Monitor for renal failure.
- B. Monitor psychosocial status.
- C. Monitor for signs of bleeding.
- D. Have heparin sodium available.
Correct Answer: C
Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.
A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:
- A. Heartburn
- B. Constipation
- C. Abdominal pain
- D. Nausea and vomiting
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals.
- B. Monitor for signs of hypoglycemia.
- C. Avoid alcohol while taking this medication.
- D. Take the medication at bedtime.
Correct Answer: C
Rationale: Clients taking metformin (Glucophage) should avoid alcohol as it can increase the risk of lactic acidosis. Metformin should be taken with meals to reduce gastrointestinal upset. While hypoglycemia is less common with metformin compared to other diabetes medications, clients should still be aware of its symptoms.
A healthcare professional is planning to administer amlodipine (Norvasc) to a client. The healthcare professional plans to check which of the following before giving the medication?
- A. Respiratory rate
- B. Blood pressure and heart rate
- C. Heart rate and respiratory rate
- D. Level of consciousness and blood pressure
Correct Answer: B
Rationale: Before administering amlodipine, it is important to check the client's blood pressure and heart rate. Amlodipine is known to lower blood pressure and heart rate as part of its mechanism of action. Monitoring these vital signs helps ensure the safety of the client and allows for appropriate assessment of the medication's effects post-administration.
The client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?
- A. Diarrhea
- B. Heartburn
- C. Flatulence
- D. Constipation
Correct Answer: B
Rationale: Omeprazole, a proton pump inhibitor, is used as an antiulcer agent to reduce gastric acid secretion. The optimal intended effect of omeprazole is the relief of pain and discomfort associated with gastric irritation, commonly referred to as heartburn. Therefore, the absence of heartburn indicates that the medication is working effectively in managing the client's gastric condition.