a nurse is preparing to administer an iv bolus of morphine to a client for pain management which of the following assessments is the nurses priority
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Nursing Elites

ATI RN

ATI Pharmacology Proctored Exam

1. A healthcare provider is preparing to administer an IV bolus of Morphine to a client for pain management. Which of the following assessments is the healthcare provider's priority?

Correct answer: A

Rationale: The priority assessment for a healthcare provider preparing to administer an IV bolus of Morphine is the client's respiratory rate. Morphine can cause respiratory depression as a significant adverse effect, so monitoring the respiratory rate is crucial to detect any signs of respiratory compromise and intervene promptly. Assessing the respiratory rate takes precedence over other assessments because respiratory depression can lead to serious complications. While pain level, blood pressure, and level of consciousness are important assessments, they are not the priority when administering Morphine, as the risk of respiratory depression is a more immediate concern.

2. A client is starting therapy with Atenolol. Which of the following adverse effects should the nurse instruct the client to monitor?

Correct answer: C

Rationale: Atenolol is a beta-blocker that can cause bradycardia as an adverse effect due to its mechanism of action in slowing down the heart rate. The nurse should instruct the client to monitor their pulse regularly and report any significant decreases to prevent complications related to bradycardia.

3. A client with renal failure and an elevated phosphorus level is prescribed aluminum hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client?

Correct answer: A

Rationale: Correct. Aluminum hydroxide is known to cause constipation as a common side effect. Instructing the client about this potential adverse effect is important for their awareness and management. The other options, metallic taste, headache, and muscle spasms, are not typically associated with aluminum hydroxide use. Therefore, the nurse should focus on educating the client about the increased risk of constipation and provide guidance on managing this side effect to improve the client's comfort and treatment adherence.

4. A client in an acute care facility is receiving IV Nitroprusside for hypertensive crisis. The nurse should monitor the client for which of the following adverse reactions to this medication?

Correct answer: C

Rationale: The correct answer is C: Delirium. When IV Nitroprusside is infused at high dosages, it can lead to thiocyanate toxicity, causing mental status changes such as delirium. It is crucial to monitor the thiocyanate levels to ensure they remain below 10 mg/dL during therapy to prevent adverse effects. Choices A, B, and D are incorrect because IV Nitroprusside is not commonly associated with intestinal ileus, neutropenia, or hyperthermia. Monitoring for delirium is crucial due to the risk of thiocyanate toxicity.

5. A client is receiving treatment with capecitabine. Which of the following findings should the nurse monitor?

Correct answer: C

Rationale: Capecitabine is known to cause neutropenia as a common adverse effect due to bone marrow suppression. Neutropenia increases the risk of infections and requires close monitoring to prevent complications. Hyperglycemia (Choice A) is not typically associated with capecitabine. Hypocalcemia (Choice B) and Bradycardia (Choice D) are not commonly linked to capecitabine use, making them incorrect choices.

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