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?

Urinary output of 20 mL within 1 hr

Blood pressure 90/60 mm Hg

Vomiting 30 mL of fluid

Respirations deep at a rate of 10/min

Answer and Explanation

The Correct Answer is D

A) Urinary output of 20 mL within 1 hr:
While low urinary output is a concern and could indicate issues such as dehydration or renal impairment, it is not the most immediate threat to the client's life when compared to respiratory depression.

B) Blood pressure 90/60 mm Hg:
A blood pressure of 90/60 mm Hg is hypotensive and should be monitored, but it is not as immediately life-threatening as respiratory depression in the context of morphine administration.

C) Vomiting 30 mL of fluid:
Vomiting is a common side effect of morphine but does not present as immediate a danger as respiratory depression. It can be managed with antiemetics and supportive care.

D) Respirations deep at a rate of 10/min:
Correct. Respiratory depression is a serious and potentially life-threatening side effect of morphine. A respiratory rate of 10 breaths per minute, even if the respirations are deep, indicates that the client's breathing is significantly slower than normal. This requires immediate attention because if untreated, it can lead to hypoxia, respiratory arrest, and death. The nurse should prioritize assessing and addressing this finding, potentially by reducing the morphine dose or administering naloxone if necessary.

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Correct Answer is A

Explanation

Answer: A. Verify a written order with the medication administration record.

A. Verify a written order with the medication administration record.
This is the correct action to ensure the right medication is administered. The nurse must compare the medication administration record (MAR) with the written order from the provider to confirm that the correct medication has been prescribed and is being administered according to the order.

B. Document the full name of the prescribed medication after administration.
While documentation is important, this step occurs after the medication has been given and does not help in ensuring that the correct medication is administered. Ensuring the right medication is given requires verification before administration, not just documentation afterward.

C. Ask another nurse to check the medication dosage prior to administration.
While it can be helpful to verify the dose with another nurse, this alone does not ensure that the correct medication is being administered. The focus here is on ensuring the right medication itself, which requires verifying the medication order with the MAR.

D. Use two client identifiers prior to administering the medication.
While using two client identifiers ensures the right client is receiving the medication, it does not address the right medication. This step is part of a separate "right" in the medication administration process—ensuring the correct patient.

A. Obtain the client's weight three times a week. B. Keep the solution refrigerated until 1 hr before infusion. C. Change the solution every 36 hr. D. Check the client's WBC count daily.

Correct Answer is B

Explanation

Answer: B. Keep the solution refrigerated until 1 hr before infusion.

Rationale:

A) Obtain the client's weight three times a week: While monitoring weight is essential to assess fluid balance and nutritional status in clients receiving TPN, daily weight measurements are more appropriate to detect rapid changes.

B) Keep the solution refrigerated until 1 hr before infusion: TPN solutions should be refrigerated to prevent bacterial growth and maintain stability. Removing the solution from refrigeration 1 hour before infusion allows it to warm to room temperature, reducing the risk of discomfort during administration.

C) Change the solution every 36 hr: TPN solutions should be changed every 24 hours to minimize the risk of bacterial contamination and infection, especially since the high glucose content is a favorable medium for bacterial growth.

D) Check the client's WBC count daily: While monitoring for infection is vital, checking the WBC count daily is not a routine requirement unless the client shows signs of infection or complications. Regular temperature checks and observing for clinical signs of infection are usually sufficient.

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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?

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