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. When educating a client who has a new prescription for Hydrochlorothiazide, which of the following statements should the nurse include?

Correct answer: B

Rationale: The correct statement to include when educating a client with a new prescription for Hydrochlorothiazide is that they may need to increase their intake of potassium. Hydrochlorothiazide is a thiazide diuretic that can lead to potassium loss. Monitoring potassium levels and increasing potassium intake if necessary can help prevent complications associated with hypokalemia. Option A is not directly related to the medication's specific instructions. Option C is incorrect as Hydrochlorothiazide typically does not cause drowsiness. Option D is unrelated, as there is no interaction between Hydrochlorothiazide and grapefruit.

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

Correct answer: A

Rationale: When a client is starting therapy with filgrastim, monitoring for bone pain is essential. Filgrastim can lead to increased bone marrow activity, resulting in bone pain as a common adverse effect. Instructing the client to monitor and report any bone pain promptly can help in managing this side effect effectively.

4. While caring for a client receiving epoetin alfa to treat anemia, which finding should the nurse monitor for?

Correct answer: B

Rationale: The nurse should monitor the client for hypertension when receiving epoetin alfa. Epoetin alfa stimulates red blood cell production, which can lead to increased blood pressure. Leukocytosis (increased white blood cells) and hyperkalemia (high potassium levels) are not typically associated with epoetin alfa therapy. Fever is also not a common adverse effect of this medication.

5. When providing teaching to a client starting therapy with trastuzumab, which finding should the nurse instruct the client to report?

Correct answer: A

Rationale: The correct answer is A: Dyspnea. The nurse should instruct the client to report dyspnea because it can indicate pulmonary toxicity, a serious adverse effect of trastuzumab. Monitoring and early reporting of respiratory symptoms like dyspnea are essential to prevent further complications and ensure timely intervention. Choices B, C, and D are incorrect because constipation, tinnitus, and dry mouth are not typically associated with trastuzumab therapy and are not priority symptoms that require immediate reporting for this specific medication.

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