A nurse is assessing a client who received morphine for severe pain 30 minutes ago. Which of the following findings is the nurse’s priority?

Last bowel movement was 3 days ago

Respiratory rate 7/min

Reports pain of 8 on a scale from 0 to 10

Distended bladder

Answer and Explanation

The Correct Answer is B

Choice A Reason:

While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression.

Choice B Reason:

A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient’s airway is maintained and to prevent respiratory arrest.

Choice C Reason:

Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient’s respiratory function takes precedence.

Choice D Reason:

A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.

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Correct Answer is B

Explanation

Choice A Reason:

Electrical wires secured to baseboards are generally not considered a significant fall risk. Properly secured wires reduce the likelihood of tripping hazards compared to loose or exposed wires. Therefore, this is not a primary concern for fall risk.

Choice B Reason:

Taking antihypertensive medication can increase the risk of falls, especially in older adults. These medications can cause orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness and an increased risk of falling. This makes it a critical factor to consider in fall risk assessments.

Choice C Reason:

Wearing rubber-sole shoes is typically recommended to prevent falls because they provide good traction and reduce the risk of slipping. However, if the soles are too thick or bulky, they can catch on carpets or other surfaces, potentially causing trips. Generally, rubber-sole shoes are considered safer than other types of footwear.

Choice D Reason:

A visual acuity of 20/40 indicates some level of visual impairment, but it is not severe. While reduced visual acuity can contribute to fall risk, it is not as significant as the risk posed by medications that affect blood pressure. Visual impairments should still be addressed, but they are not the most immediate concern in this context.

A. Seat the client in a chair for 30 minutes prior to applying the stockings. B. Measure the length of the client’s leg from the heel to the gluteal fold. C. Instruct the client to point their toes while applying the stockings. D. Roll the top of the client’s stockings down to just below the knee.

Correct Answer is B

Explanation

Choice A Reason: Seat the client in a chair for 30 minutes prior to applying the stockings.

Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.

Choice B Reason: Measure the length of the client’s leg from the heel to the gluteal fold.

Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.

Choice C Reason: Instruct the client to point their toes while applying the stockings.

Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.

Choice D Reason: Roll the top of the client’s stockings down to just below the knee.

Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.

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