A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

Vomiting 30 mL of fluid

Blood pressure 90/60 mm Hg

Respirations deep at a rate of 10/min

Urinary output of 20 mL within 1 hr

Answer and Explanation

The Correct Answer is C

A. Vomiting 30 mL of fluid. This finding is not the priority because while vomiting can be a side effect of morphine, it is not immediately life-threatening.
B. Blood pressure 90/60 mm Hg. This finding is concerning but not the priority. Morphine can cause hypotension, but the primary concern with morphine administration is respiratory depression.
C. Respirations deep at a rate of 10/min. This finding is the priority because morphine can cause respiratory depression, which can be life-threatening. Monitoring and addressing respiratory status is critical when administering opioids.
D. Urinary output of 20 mL within 1 hr. This finding is concerning but not the priority. Low urinary output can indicate dehydration or renal issues, but respiratory depression is the most immediate concern with morphine administration.

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Correct Answer is C

Explanation

A. “Call 911 if pain persists 30 minutes after taking one tablet” is incorrect. The client should call 911 if chest pain persists after taking three doses of nitroglycerin at 5-minute intervals, not 30 minutes.
B. “Take a tablet every 10 minutes until the pain subsides” is incorrect. The correct instruction is to take one tablet every 5 minutes, up to three tablets, and seek emergency help if the pain does not subside.
C. “Place the tablet under the tongue until dissolved” is correct. Sublingual nitroglycerin should be placed under the tongue to dissolve, allowing for rapid absorption and relief of angina.
D. “Store the tablets in a refrigerator in a plastic container” is incorrect. Nitroglycerin tablets should be stored at room temperature in their original glass container to maintain potency.

A. Check the client’s medical record for medication and food interactions. B. Consult a drug reference guide for possible interactions. C. Ask another nurse if they are aware of potential interactions. D. Have the client take the medication on an empty stomach to avoid interactions.

Correct Answer is B

Explanation

A. Check the client’s medical record for medication and food interactions is important, but it may not provide comprehensive information about all potential interactions.
B. Consult a drug reference guide for possible interactions is the best action. Drug reference guides provide detailed and up-to-date information about potential food and medication interactions, ensuring safe administration.
C. Ask another nurse if they are aware of potential interactions can be helpful, but it should not be the primary source of information. It is better to rely on authoritative drug reference guides.
D. Have the client take the medication on an empty stomach to avoid interactions is not always appropriate. Some medications need to be taken with food to enhance absorption or reduce gastrointestinal side effects.

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A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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