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

Respiratory rate 7/min

Distended bladder

Last bowel movement was 3 days ago

Reports pain of 8 on a scale from 0 to 10

Answer and Explanation

The Correct Answer is A

A.   A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B.   While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C.   Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D.   Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.

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Correct Answer is B

Explanation

A. Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B. Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C. Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D. Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.

A. Release the skin before withdrawing the needle. B. Insert at a 45° angle. C. Withdraw the needle quickly. D. Pull the skin laterally.

Correct Answer is D

Explanation

A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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