A nurse is assessing a client's response to receiving morphine for postoperative pain management. Which of the following findings is the nurse's priority?
Hypotension
Bradycardia
Bradypnea
Pruritus
The Correct Answer is C
A. Hypotension: While hypotension can be a concern with opioid use, it is less immediately life-threatening compared to respiratory depression, which is the most dangerous side effect of morphine. Monitoring BP is important, but the priority is airway and breathing.
B. Bradycardia: Bradycardia is a possible side effect of morphine, but it does not usually present an immediate risk to the client's life unless it is severe. Respiratory depression poses a greater risk to the client’s oxygenation status.
C. Bradypnea: Bradypnea (slow breathing) is the most critical concern when a client is receiving morphine. Opioids like morphine can cause respiratory depression, which can be life-threatening. This should be the nurse's priority to assess and address immediately.
D. Pruritus: Pruritus (itching) is a common side effect of morphine, but it is not life-threatening. While it can be uncomfortable, it does not require immediate intervention compared to respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.
B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.
C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.
D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.
Correct Answer is C
Explanation
A. Temperature 38.7° C (101.7° F): A temperature of 38.7° C (101.7° F) is elevated and may indicate an infection or inflammation, which is not expected after an EGD. A mild fever could occur briefly, but temperatures above 100.4° F should be monitored closely.
B. Heart rate 110/min: A heart rate of 110/min is elevated and may suggest tachycardia due to pain, anxiety, or potential complications. An elevated heart rate should be assessed further, as it is not typical during the recovery phase of an EGD procedure.
C. Respiratory rate 14/min: A respiratory rate of 14/min is within the normal range for an adult (12-20/min), indicating that the client is breathing comfortably and is recovering well from the procedure. This is an expected finding post-procedure.
D. SpO2 92%: An SpO2 level of 92% is slightly low. The normal range for oxygen saturation is typically 95-100%, and a reading of 92% may indicate mild hypoxemia, which should be further evaluated, especially if the client is recovering from sedation.
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