A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?
Bowel sounds
Respiratory rate
Urine output
Pupil reaction
The Correct Answer is B
A. While morphine can affect bowel sounds by causing constipation, this is not the priority assessment before administration.
B. Respiratory rate is the priority assessment because morphine can cause respiratory depression, which is a life-threatening side effect.
C. Urine output is important to monitor for overall kidney function and hydration status but is not the immediate priority before administering morphine.
D. Pupil reaction can indicate opioid effects, but monitoring respiratory status is more critical.
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Related Questions
Correct Answer is D
Explanation
A. Administering a bolus dose of morphine at PCA initiation is a common practice.
B. Monitoring the frequency of button presses and understanding the lockout period is appropriate.
C. Educating the family not to push the PCA button is correct and ensures patient safety.
D. Discarding the remaining medication should be witnessed and documented correctly, but the process should follow the institution’s protocol, and witnessing should have been done before discarding, not after.
Correct Answer is A
Explanation
A. Tolerance to opioids like morphine means that over time, the client needs higher doses to achieve the same level of pain relief.
B. Episodes of confusion do not explain the need for increased doses of morphine.
C. Improper medication administration could lead to underdosing, but this is less likely than tolerance in the context of terminal cancer pain management.
D. Addiction is characterized by compulsive use despite harm, but increased dosing for pain relief in a terminally ill client is more likely due to tolerance.
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