A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?
Pupil diameter 6 mm
Blood pressure 80/40 mm Hg
Urinary output 120 mL/4 hr
Bowel movement 5 days ago
The Correct Answer is B
Rationale:
A. Pupil diameter 6 mm: Dilated pupils may indicate CNS stimulation or sensitivity, but this finding is less immediately life-threatening than significant hypotension. Pupil size should still be monitored, especially for signs of overdose or neurologic changes.
B. Blood pressure 80/40 mm Hg: Severe hypotension is a critical adverse effect of IV morphine that can compromise perfusion to vital organs. It requires immediate attention to prevent shock, making this the highest priority finding to report.
C. Urinary output 120 mL/4 hr: While this output is slightly below normal, it does not yet indicate acute kidney injury. Continued monitoring is warranted, but it is not the most urgent issue compared to hypotension.
D. Bowel movement 5 days ago: Constipation is a common side effect of opioids, but it typically develops gradually and can be managed with bowel protocols. It is not as urgent as hypotension and can be addressed after stabilizing the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.
B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.
C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.
D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.
Correct Answer is D
Explanation
Rationale:
A. Request a change in medication from the provider: Medication adjustments should be based on a full assessment of the child’s symptoms and patterns. Requesting a change prematurely may lead to ineffective or inappropriate treatment.
B. Refer the family to a chronic pain support group: Support groups are helpful for long-term coping and education, but they are not an immediate action. The nurse must first assess the current situation to guide any referrals.
C. Set up an appointment with the school nurse: While school involvement can support symptom management, especially for triggers or academic impact, it is not the initial step. The nurse must first gather complete data on the headaches.
D. Review the child's electronic pain diary: The pain diary provides detailed information about frequency, triggers, intensity, and patterns of the migraines. Reviewing it is the first step to making informed decisions about the child’s care plan.
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