A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
Stevens-Johnson syndrome
Hypertension
Prolonged wound healing
Bradypnea
The Correct Answer is D
A. Stevens-Johnson syndrome is a severe, rare, and potentially life-threatening reaction that can occur as a hypersensitivity reaction to certain medications. However, it is not typically associated with morphine use.
B. Morphine is more commonly associated with hypotension rather than hypertension. Therefore, while monitoring for changes in blood pressure is important, hypertension is not a primary concern with morphine administration.
C. Morphine use is not typically associated with prolonged wound healing. However, it can cause respiratory depression, which can indirectly affect wound healing by reducing tissue oxygenation.
D. Morphine is a potent opioid analgesic that can cause respiratory depression, leading to bradypnea (slow breathing) or even respiratory arrest. Monitoring respiratory rate is crucial when administering morphine to detect signs of respiratory depression early and intervene promptly.
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Related Questions
Correct Answer is C
Explanation
- A: Riding against the flow of traffic is unsafe because it increases the likelihood of an accident. Drivers do not expect to see cyclists coming from the opposite direction and may not have enough time to react if they encounter one.
- B: Keeping the bicycle at least 3 feet from the curb is not always practical or safe. It may place the cyclist in the path of moving traffic, which can be dangerous, especially for children who may not have the experience to navigate around cars safely.
- C: Walking the bicycle through intersections is a safe practice because it allows the child to navigate the intersection without being in the path of cars, giving them time to look for oncoming traffic and proceed when it is safe.
- D: The child's feet should be able to touch the ground when seated on the bicycle. This ensures that the child can maintain balance and control of the bicycle, especially in situations where they need to stop quickly.
Correct Answer is D
Explanation
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
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