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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Let's discuss some weight loss strategies that might work for you.": While well-intentioned, this response shifts focus prematurely to problem-solving rather than acknowledging the client's immediate emotional distress. It can come across as dismissive of the client's feelings and reinforce stigma.
B. "Have you always felt uncomfortable being overweight?": This question delves into the client's history without first validating their current emotional state. It may seem intrusive and bypasses the opportunity to provide empathy in the moment.
C. "How long have you struggled with your weight?": This response centers on the weight issue rather than addressing the client’s expressed feelings of being stared at and judged. It risks making the client feel pathologized rather than supported.
D. “It sounds like you're saying that you feel uncomfortable around others.”: This therapeutic response reflects the client's feelings, validates their emotional experience, and encourages further expression. It helps build trust and demonstrates empathy without judgment.
Correct Answer is C
Explanation
Rationale:
A. Tomato allergy: A tomato allergy is not relevant to the ingredients used in total parenteral nutrition (TPN) with fat emulsion. Tomatoes are not a component of lipid emulsions, so this does not present a concern in this context.
B. Citrus allergy: Citrus fruits are also not involved in the formulation of fat emulsions or TPN components. Therefore, a citrus allergy would not require special precautions related to the prescribed therapy.
C. Egg allergy: Lipid emulsions used in TPN often contain egg phospholipids as an emulsifying agent. Clients with an egg allergy may experience a hypersensitivity reaction, making this a critical finding that must be reported to the provider immediately.
D. Wheat allergy: Wheat is not a component of standard TPN or fat emulsions. While wheat allergies are significant for dietary intake, they do not pose a known risk with parenteral nutrition administration.
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