A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Sleepy, but arousing when the name is called.
Pain level of 6 on a scale from 0 to 10.
Respiratory rate of 8/min.
SaO2 94%
The Correct Answer is C
Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.
Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.
Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.
Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because staying well hydrated can help prevent gout attacks and kidney stones, which can be a side effect of allopurinol.
Choice B reason: This is incorrect. Aspirin can interfere with allopurinol and may increase the risk of gout attacks; therefore, it is not recommended without consulting a healthcare provider.
Choice C reason: This is incorrect. Allopurinol does not need to be taken on an empty stomach; it can be taken with or without food.
Choice D reason: This is correct. Allopurinol should not be crushed or chewed; it should be swallowed whole.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Enlarged distal extremities are a classic sign of acromegaly due to the overproduction of growth hormone, which affects the growth plates in the bones.
Choice B reason: Coarse facial features, including a protruding jaw and brow, enlarged nose, and thickened lips, are common in acromegaly due to the excessive growth of facial bones and soft tissues.
Choice C reason: Loss of color discrimination is not typically associated with acromegaly. This symptom may be related to other conditions affecting the optic nerve or the brain.
Choice D reason: Hepatomegaly, or an enlarged liver, can occur in acromegaly as a result of increased growth factor effects on the liver.
Choice E reason: Moon face is associated with conditions that lead to corticosteroid excess, such as Cushing's syndrome, but can also appear in acromegaly due to soft tissue swelling.
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