A nurse in an emergency department is caring for a client who has morphine toxicity. Which of the following medications should the nurse anticipate administering to the client?

Rationale:

A. There is no universal minimum age of 21 for organ donation. In many jurisdictions, individuals as young as 18 can legally consent to organ donation. Additionally, minors may be able to donate with parental or guardian consent depending on local laws. Therefore, this statement provides inaccurate information.

B. Organ donation registration is typically voluntary and can be changed or revoked at any time by the individual while they are alive and competent. Many organ donor registries allow individuals to update or remove their consent status, so the statement is false.

C. Consent for organ donation must be formally documented, commonly through written consent such as signing a donor registry, indicating it on a driver’s license, or completing legal donor authorization forms. This ensures that the individual’s wishes are clearly recorded and legally recognized.

D. There is no general rule that prohibits a nurse from acting as a witness for organ donation consent. Institutional policies may vary, but nurses are often permitted to witness consent forms as part of their professional role unless there is a conflict of interest or specific policy restriction. Therefore, this statement is not universally true and should not be presented as a standard rule.

Rationale for Correct Answers:

• Sudden onset of dyspnea and chest discomfort: Any sudden respiratory distress or chest pain post-surgery is a red flag for pulmonary embolism or myocardial infarction.
• Client is tachypneic and appears in distress: Rapid breathing and physical signs of distress indicate the client is struggling to maintain adequate ventilation and oxygenation.
• S3 and S4 heart sounds noted: The presence of extra heart sounds can indicate acute heart failure or ventricular strain, which may occur if the heart is struggling against a pulmonary obstruction.
• Respiratory rate 34/min: This is significantly above the normal range (12–20/min) and confirms severe tachypnea.
• Oxygen saturation 92% on 2 L/min via nasal cannula: Despite receiving supplemental oxygen, the saturation is below the expected 95–100%, indicating impaired gas exchange.

Rationale for Incorrect Answers:

• Client is awake and orientated x4: While positive, this is a baseline neurologic expectation and does not represent an acute deterioration in this context.
• Bilateral pedal pulses are +1: While slightly diminished, the fact that they are bilateral and present suggests peripheral perfusion is occurring, though this should be monitored relative to the client's baseline.
• Blood pressure 144/72 mm Hg: While slightly elevated, this is relatively stable compared to the 0900 reading (142/68) and is not as immediate a priority as the respiratory distress.