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

Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly.

Choice B Reason

When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely.

Choice C Reason

Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process.

Choice D Reason

Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.

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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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?

Nursing Test Bank

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