what is the priority assessment for a patient receiving intravenous morphine
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Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam

1. What is the priority assessment for a patient receiving intravenous morphine?

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

2. The patient is receiving a high dose of tetracycline (Sumycin). Which laboratory values should the nurse monitor while caring for this patient?

Correct answer: A

Rationale: High doses of tetracyclines can lead to nephrotoxicity, especially when given along with other nephrotoxic drugs. Renal function tests, such as monitoring blood urea nitrogen (BUN) and creatinine levels, should be performed to assess for nephrotoxicity. Monitoring complete blood counts (choice B) is not directly related to tetracycline therapy. Checking electrolytes (choice C) is important but not the priority when monitoring for tetracycline-induced nephrotoxicity. Monitoring liver enzyme levels (choice D) is not typically indicated in the context of tetracycline therapy.

3. A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to:

Correct answer: A

Rationale: During illness, individuals with type 1 diabetes mellitus may experience increased insulin requirements due to factors such as stress and the release of counterregulatory hormones. Increasing the frequency of self-monitoring, as stated in choice A, is crucial to closely monitor and adjust insulin doses as needed. Choice B, reducing food intake to alleviate nausea, is incorrect as it may lead to hypoglycemia and does not address the increased insulin needs during illness. Choice C, discontinuing the insulin dose if unable to eat, is dangerous as it can result in uncontrolled hyperglycemia. Choice D, taking the normal dose of insulin, may not be sufficient during illness when insulin requirements are likely elevated.

4. What is a priority goal for the diabetic client who is taking insulin and experiencing nausea and vomiting from a viral illness or influenza?

Correct answer: A

Rationale: Ensuring adequate food intake is a priority goal for a diabetic client taking insulin and experiencing nausea and vomiting due to a viral illness or influenza because maintaining proper nutrition is essential to prevent complications such as ketoacidosis. During illness, it is crucial for diabetic individuals to continue to consume appropriate amounts of food to maintain stable blood sugar levels and prevent hypoglycemia. Managing personal health (choice B) is important but not the priority in this situation. Relieving pain (choice C) may be necessary if present but is not the priority over ensuring food intake. Increasing physical activity (choice D) is not recommended during illness, especially when the individual is experiencing nausea and vomiting.

5. In a patient with diabetes, which of the following is a sign of hypoglycemia?

Correct answer: D

Rationale: Sweating is a common sign of hypoglycemia in patients with diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, leading to symptoms such as sweating, shakiness, and palpitations. Polydipsia (excessive thirst) and polyuria (excessive urination) are more commonly associated with hyperglycemia (high blood sugar levels) in diabetes. Dry skin is not a typical symptom of hypoglycemia.

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