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?

Choice A reason: Drive the client to the nearest emergency department

While it might seem helpful to drive the client to the nearest emergency department, it is not the best course of action. The symptoms described—right-sided weakness and slurred speech—are indicative of a possible stroke. Time is critical in stroke management, and emergency services can provide immediate medical intervention and transport to a stroke center, which is essential for the best possible outcome.

Choice B reason: Call emergency services

Calling emergency services is the most appropriate action. The client is exhibiting signs of a stroke, and rapid medical intervention is crucial. Emergency medical services (EMS) can begin treatment en route to the hospital and ensure the client is taken to a facility equipped to handle strokes. This action maximizes the chances of a positive outcome by minimizing delays in treatment.

Choice C reason: Find a location for the client to sit

Finding a location for the client to sit might provide temporary comfort, but it does not address the urgent need for medical intervention. In the case of a suspected stroke, immediate action is necessary to prevent further damage. Sitting the client down does not provide the critical care needed in this situation.

Choice D reason: Obtain the telephone number of the client’s provider

Obtaining the telephone number of the client’s provider is not the priority in an emergency situation like this. While it might be useful information later, the immediate need is to get the client to a hospital as quickly as possible. Contacting the provider can be done after emergency services have been called.

Choice A reason: Reinforce discharge teaching to clients

While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.

Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs

Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.

Choice C reason: Stock additional unit supplies

Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.

Choice D reason: Focus on providing care that prevents life-threatening emergencies

Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.