A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Sleepy, but arousing when her name is called.
Respiratory rate 8/min.
Pain level of 6 on a scale from 0 to 10.
The Correct Answer is B
Choice A reason:
Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.
Choice B reason:
A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.
Choice C reason:
A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Testing new nurses for exposure to tuberculosis
Testing new nurses for exposure to tuberculosis is an example of secondary prevention. Secondary prevention aims to detect and treat diseases early, often before symptoms are present, to minimize serious consequences. This activity involves screening and early detection, which are hallmarks of secondary prevention.
Choice B reason: Providing treatment for clients who have chronic obstructive pulmonary disease
Providing treatment for clients who have chronic obstructive pulmonary disease (COPD) is an example of tertiary prevention. Tertiary prevention focuses on managing existing diseases to prevent complications, reduce disability, and improve quality of life. This includes ongoing treatment and rehabilitation efforts to manage chronic conditions effectively.
Choice C reason: Performing screening for sexually transmitted infections
Performing screening for sexually transmitted infections (STIs) is another example of secondary prevention. Screening programs aim to detect diseases early, often before symptoms appear, to provide timely treatment and prevent further spread. This activity is crucial for early intervention and control of infectious diseases.
Choice D reason: Administering influenza immunizations at a local health fair
Administering influenza immunizations is an example of primary prevention. Primary prevention aims to prevent diseases from occurring in the first place through measures such as vaccinations, health education, and lifestyle modifications. Immunizations are a key component of primary prevention strategies.
Correct Answer is B
Explanation
Choice A reason: Hypothermia
Hypothermia, or abnormally low body temperature, is not a typical manifestation of acute osteomyelitis. Osteomyelitis usually presents with signs of infection, such as fever, rather than a drop in body temperature. Therefore, hypothermia is not a relevant symptom in this context.
Choice B reason: Localized edema
Localized edema, or swelling, is a common symptom of acute osteomyelitis. The infection in the bone can cause inflammation and swelling in the surrounding tissues. This is often accompanied by warmth and redness over the affected area. Therefore, localized edema is a key manifestation of acute osteomyelitis.
Choice C reason: Numbness of toes on the affected foot
Numbness of the toes is not a typical symptom of acute osteomyelitis. While nerve involvement can occur in severe cases, it is not a primary manifestation. Acute osteomyelitis primarily presents with signs of infection and inflammation, such as pain, swelling, and redness.
Choice D reason: Bradycardia
Bradycardia, or a slow heart rate, is not associated with acute osteomyelitis. The condition typically presents with systemic signs of infection, such as fever and malaise, rather than changes in heart rate. Bradycardia is more commonly related to cardiac conditions or certain medications.
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