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?
Urinary output 120 mL/4 hr
Pupil diameter 6 mm
Bowel movement 5 days ago
Blood pressure 80/40 mm Hg
The Correct Answer is D
A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
- Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
- Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
- Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
- Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
- Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.
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