the nurse is caring for a client who is receiving intravenous iv morphine for pain control which assessment finding requires the most immediate interv
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ATI Learning System PN Medical Surgical Final Quizlet

1. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

2. The client has been prescribed metformin (Glucophage) for type 2 diabetes. Which instruction should the nurse include in discharge teaching?

Correct answer: B

Rationale: The correct instruction for taking metformin (Glucophage) is with meals. This helps reduce gastrointestinal side effects and improves the medication's absorption. Taking it on an empty stomach can lead to more adverse effects, so it is essential to take it with food. Option A ('Take the medication at bedtime') is incorrect because metformin should be taken with meals to enhance its effectiveness and reduce side effects. Option C ('Take the medication on an empty stomach') is incorrect as taking metformin on an empty stomach can increase the likelihood of experiencing gastrointestinal issues. Option D ('Take the medication as needed for high blood sugar') is incorrect because metformin is typically taken regularly as prescribed, not just as needed for high blood sugar.

3. A patient with rheumatoid arthritis is taking prednisone. What is an important side effect for the nurse to monitor?

Correct answer: A

Rationale: The correct answer is hyperglycemia. Prednisone, a corticosteroid, can lead to elevated blood sugar levels as a side effect, particularly in patients with diabetes or those predisposed to developing diabetes. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome.

4. A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?

Correct answer: D

Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT. Applying a warm compress (Choice A) could worsen the condition by increasing blood flow. Elevating the leg (Choice B) might be contraindicated in DVT as it can dislodge a clot. Measuring the circumference of the leg (Choice C) is not the priority at this time compared to promptly involving the healthcare provider.

5. When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?

Correct answer: D

Rationale: The client with a pneumothorax and a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration.

Similar Questions

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