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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Discard expired medication down the toilet":
Incorrect. Flushing medications down the toilet can lead to contamination of water supplies and harm the environment. This method is not recommended except for certain medications that specifically instruct this disposal method.
B) "Pour expired medication tablets into a waste basket":
Incorrect. Disposing of medication in a waste basket can pose risks of accidental ingestion by children, pets, or wildlife, and it does not prevent the potential misuse of medications.
C) "Return expired medication to the pharmacist":
Correct. Returning expired medications to the pharmacist is the safest and most environmentally friendly option. Pharmacists can ensure the medications are disposed of properly according to local regulations, which may include methods like incineration or using drug take-back programs.
D) "Crush expired medication tablets and rinse them down the sink":
Incorrect. Similar to flushing down the toilet, rinsing crushed medications down the sink can lead to water contamination. This method is not environmentally safe.
Correct Answer is A
Explanation
A) "Your urine will turn orange while you are taking this medication":
Correct. Rifampin is known to cause orange discoloration of bodily fluids, including urine, sweat, saliva, and tears. Informing the client about this common side effect helps alleviate concerns and ensures they are aware of the medication's expected effects.
B) "You should take this medication once each day at bedtime":
Incorrect. Rifampin is typically prescribed once daily, but the timing may vary based on the specific regimen prescribed by the healthcare provider. It is essential for the nurse to provide accurate information about the dosing schedule based on the client's prescription.
C) "You can continue to wear soft contact lenses while taking this medication":
Incorrect. Rifampin can cause discoloration of contact lenses. Therefore, clients should be advised to avoid wearing soft contact lenses during treatment to prevent staining.
D) "This medication will not interfere with the effectiveness of oral contraceptives":
Incorrect. Rifampin is a known inducer of hepatic enzymes, which can accelerate the metabolism of oral contraceptives and reduce their effectiveness. Clients taking rifampin should be informed about the potential for decreased contraceptive efficacy and advised to use additional or alternative methods of contraception during treatment.
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