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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Securing electrical wires reduces tripping hazards and promotes safety.
B. Rubber-sole shoes provide better traction and reduce the risk of slips and falls.
C. Reduced visual acuity increases the risk of falls but not as much as taking antihypertensives do.
D. Taking an antihypertensive medication can be a potential fall risk, because it can cause hypotension and dizziness.
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