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?
Bradypnea
Bradycardia
Hypotension
Pruritus
The Correct Answer is A
A. Bradypnea (abnormally slow breathing) is the priority finding because it can indicate respiratory depression, a life-threatening adverse effect of morphine that requires immediate intervention.
B. Bradycardia is a possible side effect but is less immediately dangerous than impaired breathing.
C. Hypotension can occur with morphine use, but it is typically manageable and not as urgent as respiratory depression.
D. Pruritus (itching) is a common, non-life-threatening side effect of morphine and can usually be treated symptomatically.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clients usually recover quickly from sedation and can often drive the next day, but this is not a key understanding about the procedure itself.
B. The doctor discussing discharge instructions after the procedure shows understanding that the client will receive post-procedure care information once awake and stable.
C. A colonoscopy does not require mechanical ventilation; sedation is usually moderate or conscious.
D. Fasting is typically required before the procedure, not after.
Correct Answer is C
Explanation
A. The affected heel should not rest directly on the bed as it increases the risk for pressure injuries. A pillow or heel protector should be used to elevate the heel off the bed.
B. Internal and external rotation of the hip is contraindicated after a hip replacement, as it can lead to dislocation of the prosthesis.
C. Using an elevated toilet seat prevents excessive hip flexion (>90 degrees), which reduces the risk of hip dislocation after surgery.
D. The client should not be turned onto the operative side immediately after surgery; instead, the client should be log rolled onto the non-operative side with an abduction pillow in place to maintain proper alignment.
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