A nurse is assessing a client prior to administering morphine. Which of the following findings indicates the nurse should withhold the morphine and contact the provider?

C. Crackles in the lungs can indicate fluid accumulation, such as pulmonary edema or pneumonia. Morphine can exacerbate respiratory conditions by depressing the respiratory drive and increasing the risk of respiratory complications. Crackles in the lungs suggest potential pulmonary issues that may compromise respiratory function. The nurse should withhold morphine and contact the provider to assess the client's respiratory status and determine if further evaluation or treatment is needed before administering morphine.

A. Urinary retention is a potential side effect of morphine. However, it is not typically a reason to withhold morphine unless it is severe or accompanied by other concerning symptoms. The nurse should monitor urinary output and consider interventions to alleviate retention if necessary, but it may not require withholding morphine alone.

B. A respiratory rate of 16 breaths per minute is within the normal range for adults. However, the nurse should assess for any signs of respiratory distress, such as shallow breathing or decreased respiratory effort, which could indicate impending respiratory depression. If there are concerns about potential respiratory depression, the nurse should withhold morphine and notify the provider for further assessment.

D. Morphine can cause bradycardia as a side effect by depressing the cardiovascular system. A heart rate of 68 beats per minute is within the normal range for adults. However, the nurse should consider the client's baseline heart rate and any signs of hemodynamic instability. If the client shows signs of significant bradycardia or other concerning cardiovascular symptoms, withholding morphine and contacting the provider for further evaluation would be appropriate.