Nursing Elites

1. A client is receiving Morphine IV for pain management. Which of the following actions should the nurse take?

• A. Monitor the client's respiratory rate every 15 minutes.
• B. Monitor the client's blood pressure every 30 minutes.
• C. Monitor the client's oxygen saturation every hour.
• D. Monitor the client's heart rate every 5 minutes.

Correct answer: A

Rationale: The correct action for the nurse is to monitor the client's respiratory rate every 15 minutes while on Morphine IV to promptly detect respiratory depression, a critical adverse effect associated with this medication. Respiratory depression is a common side effect of opioid medications like Morphine and can be life-threatening. Monitoring the respiratory rate frequently enables the nurse to identify early signs of respiratory compromise and intervene promptly. Monitoring other vital signs like blood pressure, oxygen saturation, or heart rate is important but not as crucial as monitoring respiratory rate when a client is on Morphine IV.

2. When administering subcutaneous enoxaparin 40 mg using a prefilled syringe of Enoxaparin 40 mg/0.4 mL to an adult client following hip arthroplasty, what action should the nurse plan to take?

• A. Expel any air bubbles from the prefilled syringe before injecting.
• B. Insert the needle completely into the client's tissue.
• C. Administer the injection in the client's thigh.
• D. Aspirate carefully after inserting the needle into the client's skin.

Correct answer: B

Rationale: When administering enoxaparin via a prefilled syringe for deep subcutaneous injection, the nurse should insert the needle completely into the client's tissue. This action ensures proper delivery of the medication into the subcutaneous layer, promoting optimal therapeutic effects. Choice A is incorrect because there is no need to expel air bubbles from a prefilled syringe. Choice C is incorrect as enoxaparin is typically administered in the abdomen for subcutaneous injections. Choice D is incorrect as aspiration is not recommended for subcutaneous injections to avoid trauma or damage to tissues.

3. A nurse is reviewing the health history of a client who has a prescription for Propranolol. Which of the following findings should the nurse report to the provider?

• A. Previous history of thromboembolism
• B. Concurrent use of an antacid
• C. History of bronchial asthma
• D. Recent weight gain

Correct answer: C

Rationale: Propranolol is a nonselective beta-blocker that can cause bronchoconstriction, making it contraindicated for clients with a history of bronchial asthma.

4. A healthcare professional is preparing to administer Butorphanol to a client who has a history of substance use disorder. The healthcare professional should identify which of the following information as true regarding Butorphanol?

• A. Butorphanol has a greater risk of abuse than morphine.
• B. Butorphanol causes a higher incidence of respiratory depression than morphine.
• C. Butorphanol cannot be reversed with an opioid antagonist.
• D. Butorphanol can cause abstinence syndrome in opioid-dependent clients.

Correct answer: D

Rationale: Corrected Rationale: Butorphanol, an opioid agonist/antagonist, can lead to abstinence syndrome in clients who are opioid-dependent. This syndrome may present with symptoms like abdominal pain, fever, and anxiety. It is crucial for healthcare professionals to consider this risk when administering Butorphanol to clients with a history of substance use disorder. Choices A, B, and C are incorrect. Butorphanol is less likely to be abused than morphine, causes less respiratory depression than morphine, and can be reversed with an opioid antagonist.

5. A client with end-stage cancer receiving Morphine is prescribed Methylnaltrexone. The client's daughter asks why the provider prescribed Methylnaltrexone. Which of the following responses should the nurse make?

• A. The medication will increase your mother's respirations.
• B. The medication will prevent dependence on the Morphine.
• C. The medication will relieve your mother's constipation.
• D. The medication works with the Morphine to increase pain relief.

Correct answer: C

Rationale: The correct response is C: 'The medication will relieve your mother's constipation.' Methylnaltrexone is an opioid antagonist used to treat severe constipation unrelieved by laxatives in opioid-dependent clients. It works by blocking the mu opioid receptors in the GI tract, which helps alleviate constipation without affecting pain relief or causing withdrawal symptoms. Choices A, B, and D are incorrect. Methylnaltrexone's primary action is related to managing constipation rather than increasing respirations, preventing dependence on Morphine, or enhancing pain relief when used alongside Morphine.

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