a nurse is preparing to administer an iv bolus of morphine to a client which of the following actions should the nurse take first
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

2. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.

3. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

4. Which medication is commonly prescribed for a patient with hypertension?

Correct answer: A

Rationale: The correct answer is Lisinopril. Lisinopril is an ACE inhibitor commonly prescribed to patients with hypertension to manage their blood pressure. Metformin is used to treat type 2 diabetes, not hypertension (choice B). Atorvastatin is a statin used to lower cholesterol levels, not primarily prescribed for hypertension (choice C). Aspirin is used for its antiplatelet effects and in preventing cardiovascular events, but it is not a first-line treatment for hypertension (choice D). Therefore, Lisinopril is the most suitable choice for a patient with hypertension.

5. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

Correct answer: D

Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.

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