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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Use the autoinjector if shortness of breath is the only symptom of anaphylaxis: An epinephrine autoinjector should be used for any signs of anaphylaxis, not just shortness of breath. Symptoms such as hives, swelling, or difficulty breathing should all trigger its use.

B. Use the second autoinjector immediately after the first dose: The second dose of epinephrine is typically used if symptoms persist or recur after 5 to 15 minutes, not immediately after the first dose. The client should call emergency services after using the first dose and only use a second dose if directed by a healthcare provider.

C. Hold the autoinjector firmly down for 10 seconds while injecting: The correct procedure for using the epinephrine autoinjector is to hold it in place for 10 seconds to ensure the full dose is administered. This is an important step to ensure the medication is fully delivered.

D. Inject into the buttock or deltoid: The epinephrine autoinjector should be injected into the outer thigh (vastus lateralis muscle), not the buttock or deltoid. The thigh muscle allows for rapid absorption of the medication in an emergency.

A. Remove weights when pulling the client up in bed. B. Check the rope for fraying every 8 hr. C. Cleanse the pin sites with hydrogen peroxide. D. Inspect the pin sites for infection every 24 hr.

Correct Answer is B

Explanation

A. Remove weights when pulling the client up in bed: Weights should never be removed from skeletal traction unless ordered by a healthcare provider. Removing weights disrupts the traction's purpose and alignment, potentially causing complications.

B. Check the rope for fraying every 8 hr: Checking the rope for fraying every 8 hours is an appropriate and safe practice in skeletal traction. Ensuring that the rope is intact and functioning properly is essential for maintaining the stability and effectiveness of the traction.

C. Cleanse the pin sites with hydrogen peroxide: Hydrogen peroxide can be too harsh for cleaning pin sites, as it may damage tissue and delay healing. A sterile saline solution is usually preferred for cleaning pin sites unless otherwise prescribed.

D. Inspect the pin sites for infection every 24 hr: Pin site inspections should be done at least once per shift, not just every 24 hours, to promptly detect any signs of infection, as early intervention is key.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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