A nurse is administering spironolactone at 0800 to a client who has heart failure.
The nurse should monitor the client for which of the following adverse effects?

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.

Choice A rationale:

A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.

Choice B rationale:

Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.

Choice C rationale:

Constipation is a common side effect of morphine and can be managed with laxatives and diet.

Choice D rationale:

Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.