a nurse is planning to administer morphine iv to a client who is postoperative which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Pharmacology Proctored Exam 2019

1. A healthcare provider plans to administer Morphine IV to a postoperative client. Which of the following actions should the provider take?

Correct answer: C

Rationale: The correct action for the provider is to withhold morphine if the client's respiratory rate is 12/min or less. Respiratory depression is a serious side effect of morphine and other opioids. Withholding the medication and informing the healthcare provider is essential to prevent further respiratory compromise in the client. Choices A, B, and D are incorrect because monitoring for seizures and confusion, protecting the client's skin from severe diarrhea, and administering morphine via IV bolus over 30 seconds or less are not the primary actions to ensure client safety when administering morphine IV. Respiratory status is crucial due to the risk of respiratory depression associated with opioid administration.

2. During the repair of a skin laceration, a client receives a local anesthetic of Lidocaine. For which of the following adverse reactions should the nurse monitor the client?

Correct answer: A

Rationale: Seizures are a potential adverse reaction following the administration of local anesthetics like Lidocaine. This adverse effect is important to monitor as it can be life-threatening and requires immediate intervention. It is crucial for the nurse to be vigilant in recognizing any signs of seizure activity to ensure the client's safety and well-being.

3. A client with cirrhosis is about to receive a dose of lactulose. The client questions the need for the medication, stating they are not constipated. The nurse should explain that lactulose is used in cirrhosis to reduce levels of which component in the bloodstream?

Correct answer: B

Rationale: Lactulose is administered to clients with cirrhosis to lower blood ammonia levels, thus aiding in the prevention of hepatic encephalopathy. Elevated ammonia levels in cirrhosis can lead to cognitive impairment and hepatic encephalopathy. Therefore, the correct answer is B (Ammonia). Glucose (Choice A) is not the component targeted by lactulose in cirrhosis. Potassium (Choice C) and Bicarbonate (Choice D) are not directly affected by lactulose administration in cirrhosis.

4. When teaching the family of a child with Cystic Fibrosis about a new prescription for Acetylcysteine, which information should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Expect this medication to smell like rotten eggs.' Acetylcysteine contains sulfur, which gives it a characteristic rotten-egg odor. This odor is normal and expected when using this medication. Choices A, C, and D are incorrect because Acetylcysteine is not used to suppress cough, cause euphoria, or change urine color. Educating the family on the distinct smell of Acetylcysteine will help them understand its characteristics and alleviate concerns about the odor.

5. A healthcare professional is caring for a client who is prescribed Metformin. Which of the following laboratory values should the healthcare professional monitor to assess for potential adverse effects?

Correct answer: D

Rationale: Corrected Rationale: Metformin can lead to lactic acidosis, especially in individuals with impaired renal function. Monitoring the client's serum creatinine levels is crucial to assess kidney function because Metformin is eliminated by the kidneys, and impaired renal function can increase the risk of adverse effects. Monitoring blood glucose levels is essential for assessing the effectiveness of Metformin in managing diabetes but is not directly related to potential adverse effects of Metformin. Creatine kinase is not typically monitored in relation to Metformin therapy. Hemoglobin A1c is used to assess long-term glucose control in diabetes but is not specific for monitoring Metformin adverse effects.

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