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 A

Explanation

A. Blood pressure is the primary assessment used to titrate a nitroprusside infusion. Nitroprusside is a potent vasodilator used to rapidly lower blood pressure in hypertensive emergencies. Continuous monitoring of blood pressure is essential to ensure the medication is titrated correctly and to avoid hypotension.
B. Stroke volume is not the primary assessment for titrating nitroprusside. While stroke volume is an important measure of cardiac function, blood pressure is the key parameter for adjusting nitroprusside dosage.
C. Urine output is an important indicator of renal function and overall fluid balance, but it is not the primary assessment for titrating nitroprusside. Blood pressure monitoring is more directly related to the effects of nitroprusside.
D. Cardiac output is an important measure of overall heart function, but it is not the primary assessment for titrating nitroprusside. Blood pressure is the most critical parameter to monitor when adjusting the infusion rate of nitroprusside.

Correct Answer is ["50"]

Explanation

Step 1: Determine the total volume to be infused. 100 mL

Step 2: Determine the time in minutes over which the infusion will be administered. 30 minutes

Step 3: Calculate the flow rate in mL/min. 100 mL ÷ 30 minutes = 3.33 mL/min

Step 4: Calculate the flow rate in gtt/min using the drop factor. 3.33 mL/min × 15 gtt/mL = 49.95 gtt/min

Step 5: Round to the nearest whole number. 50 gtt/min

The nurse should set the manual IV infusion to deliver 50 gtt/min.

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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

A nurse is preparing to titrate a continuous nitroprusside infusion for a client. The nurse should plan to titrate the infusion according to which of the following assessments?

Correct Answer is A

Explanation

Correct Answer is ["50"]

Explanation

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