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 C

Explanation

A. Clean gloves are typically sufficient for wound care, and the use of sterile gloves may not be necessary for routine dressing changes.
B. Frequent dressing changes can disrupt wound healing and increase the risk of infection. Dressings should be changed according to the healthcare provider's instructions, which are typically less frequent.
C. When cleaning the wound, it is important to start from the incision site and work outward to avoid introducing contaminants into the wound.
D. Tincture of benzoin is a skin adhesive and may not be routinely used for dressing changes, especially if it is not specified in the healthcare provider's orders.

A. Use sterile gloves to obtain the sputum specimen. B. Place the sputum specimen in a clean container. C. Collect the sputum specimen in the morning. D. Obtain the sputum specimen after the client uses mouthwash.

Correct Answer is C

Explanation

A. Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.

B. Sputum specimens should be collected in a sterile container to prevent contamination.
C. Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D. Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.

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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?

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