Nokea
A healthcare professional is caring for a client who has a new prescription for Morphine to manage post-operative pain. Which of the following assessments should the healthcare professional perform first?
- A. Urine output
- B. Bowel sounds
- C. Pain level
- D. Respiratory rate
Correct Answer: D
Rationale: The healthcare professional should prioritize assessing the client's respiratory rate because respiratory depression is a life-threatening adverse effect of Morphine. Monitoring the respiratory rate allows for early detection of potential complications and timely intervention to prevent harm. Assessing urine output, bowel sounds, and pain level are important but should come after ensuring the client's respiratory status is stable as it is the most critical assessment to prevent serious complications associated with opioid use.
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A nurse is providing teaching for a male client who has Schizophrenia and is taking Risperidone. Which of the following instructions should the nurse include in the teaching?
- A. Add extra snacks to your diet to prevent weight loss.
- B. Notify the provider if you develop breast enlargement.
- C. You may begin to have mild seizures while taking this medication.
- D. This medication is likely to increase your libido.
Correct Answer: B
Rationale: The correct answer is B: 'Notify the provider if you develop breast enlargement.' Gynecomastia (breast enlargement) and galactorrhea can occur due to an increase in prolactin levels while taking risperidone. The client should inform the provider if these manifestations occur. Choices A, C, and D are incorrect. Adding extra snacks to the diet to prevent weight loss is not a specific instruction related to risperidone. Seizures are not a common side effect of risperidone, so the statement about mild seizures is inaccurate. Risperidone is more likely to cause sexual side effects like erectile dysfunction rather than increasing libido, making choice D incorrect.
While assessing a client taking Amiodarone to treat Atrial Fibrillation, which of the following findings is indicative of Amiodarone toxicity?
- A. Light yellow urine
- B. Report of tinnitus
- C. Productive cough
- D. Blue-gray skin discoloration
Correct Answer: C
Rationale: Productive cough can indicate pulmonary toxicity, which is a known adverse effect of Amiodarone. Clients on Amiodarone should be monitored for signs of pulmonary toxicity such as cough, dyspnea, and chest pain. This is important to detect early and prevent serious complications. The other options are not typically associated with Amiodarone toxicity. Light yellow urine is not a common sign, tinnitus is more related to ear problems, and blue-gray skin discoloration is not a recognized symptom of Amiodarone toxicity.
A healthcare professional is preparing to administer an IV bolus of Morphine to a client for pain management. Which of the following assessments is the healthcare professional's priority?
- A. Respiratory rate
- B. Pain level
- C. Blood pressure
- D. Level of consciousness
Correct Answer: A
Rationale: The priority assessment for a client receiving an IV bolus of Morphine is the respiratory rate. Morphine can cause respiratory depression, which is a serious adverse effect. Monitoring the respiratory rate is crucial to detect any signs of respiratory compromise early and intervene promptly. Assessing pain level, blood pressure, and level of consciousness are also important but not the priority in this situation. Pain level can be assessed after ensuring the client's respiratory status is stable. Blood pressure and level of consciousness should be monitored but do not take precedence over the respiratory rate when administering Morphine.
A client is receiving long-term aspirin therapy. The healthcare provider should monitor the client for which of the following complications?
- A. Hemorrhagic stroke
- B. Thromboembolic stroke
- C. Iron deficiency anemia
- D. Neutropenia
Correct Answer: A
Rationale: The correct answer is A: Hemorrhagic stroke. Long-term aspirin therapy can lead to hemorrhagic stroke due to its antiplatelet effects, which increase the risk of bleeding. Aspirin inhibits platelet aggregation, which can predispose the individual to bleeding complications, including hemorrhagic stroke. Choices B, C, and D are incorrect because aspirin therapy is more likely to cause bleeding complications rather than thromboembolic events, iron deficiency anemia, or neutropenia.
When teaching a client with a new prescription for Furosemide, which instruction should the nurse include?
- A. Take this medication at bedtime.
- B. Avoid eating foods high in potassium.
- C. Change positions slowly.
- D. Take this medication with meals.
Correct Answer: C
Rationale: The correct instruction for a client with a new prescription for Furosemide is to change positions slowly. Furosemide is a diuretic that can lead to orthostatic hypotension, causing dizziness and increasing the risk of falls. By advising the client to change positions slowly, the nurse helps prevent these potential adverse effects. Choices A, B, and D are incorrect. Taking Furosemide at bedtime (Choice A) is not necessary as it can be taken at any time of the day. Avoiding foods high in potassium (Choice B) is more relevant for clients taking potassium-sparing diuretics. Taking Furosemide with meals (Choice D) may lead to increased diuretic effects and frequent urination.