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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

A. "The estimated blood loss was 250 milliliters." B. "The client was intubated without complications." C. "There was a total of 10 sponges used during the procedure." D. The client is a member of the board of directors."

Correct Answer is A

Explanation

A. "The estimated blood loss was 250 milliliters." This is a relevant clinical detail that directly impacts the client’s postoperative care. It provides important information for ongoing assessment of fluid status, potential for anemia, and need for interventions.
B. "The client was intubated without complications." While important during surgery, this is less relevant in the postoperative period unless the intubation caused complications or the client remains intubated. It does not guide current nursing care.
C. "There was a total of 10 sponges used during the procedure." Sponge counts are part of surgical safety and accountability, but they are not typically necessary in nursing hand-off unless a retained item is suspected.
D. "The client is a member of the board of directors." This is not clinically relevant and could breach confidentiality or bias care. Hand-off reports should focus solely on the client’s medical condition and nursing care needs.

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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?

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