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?
Urinary retention
Respiratory rate 16/min
Crackles in the lungs
Heart rate 68/min
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Epoetin alfa is often administered subcutaneously to provide a slow and sustained release of the medication into the bloodstream. Subcutaneous administration allows for easy access to fatty tissue beneath the skin and provides a suitable absorption rate for the medication.
A. Epoetin alfa is a protein-based medication that would be broken down by digestive enzymes in the gastrointestinal tract, rendering it ineffective if taken orally. Therefore, oral administration is not suitable for epoetin alfa.
C. Epoetin alfa molecules are too large to pass through the skin barrier effectively. Transdermal delivery systems are typically used for medications that are small, lipid-soluble, and can penetrate the skin's layers to enter the bloodstream.
D. Epoetin alfa is not formulated for absorption through nasal mucosa. Intranasal administration is generally reserved for medications that can be absorbed through the nasal membranes, such as certain hormones or medications for nasal conditions.
Correct Answer is B
Explanation
B. Hearing loss can indeed be an adverse effect associated with furosemide use, especially when high doses are administered rapidly intravenously or when the medication is used long-term. This occurs due to furosemide's potential to cause ototoxicity, affecting the inner ear and leading to hearing impairment.
A. Furosemide is not known to increase blood pressure. In fact, it typically helps reduce blood pressure by reducing fluid volume through its diuretic action. Therefore, increased blood pressure would not be an adverse effect of furosemide.
C Ankle edema is not typically an adverse effect of furosemide. In fact, furosemide is used to treat edema by reducing fluid retention, so the presence of ankle edema would indicate inadequate response to the medication or progression of the underlying condition.
D. Furosemide is not known to cause decreased blood sugar levels. Instead, it can cause electrolyte imbalances such as hypokalemia (low potassium levels), which might manifest with symptoms similar to hypoglycemia but does not directly lower blood sugar levels.
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