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 D

Explanation

A. “Insomnia”: While insomnia can be a side effect of many medications, it is not typically associated with carbamazepine. Carbamazepine, an anticonvulsant, is used to control seizures and does not commonly cause insomnia.

B. “Tachypnea”: Tachypnea, or rapid breathing, is not a common side effect of carbamazepine. Carbamazepine does not typically affect the respiratory system in this way.

C. “Metallic taste”: A metallic taste is not a common side effect of carbamazepine. This side effect is more commonly associated with certain antibiotics or antifungal medications.

D. “Blurred vision”: This is the correct answer. Blurred vision is a known side effect of carbamazepine. If a client experiences this side effect, they should notify their healthcare provider as it may indicate a need for dosage adjustment or a change in medication. It’s important for clients to be aware of this potential side effect so they can monitor for it and seek medical attention if it occurs.

A. Propafenone B. Metformin C. Prochlorperazine D. Simvastatin

Correct Answer is C

Explanation

A) Propafenone:
Propafenone is an antiarrhythmic medication used to treat irregular heartbeats. It is not indicated for the treatment of vomiting and may exacerbate gastrointestinal symptoms.

B) Metformin:
Metformin is an oral medication commonly used to treat type 2 diabetes. It is not indicated for the treatment of vomiting and may exacerbate gastrointestinal symptoms in some individuals.

C) Prochlorperazine:
Prochlorperazine is an antiemetic medication commonly used to treat nausea and vomiting. It works by blocking dopamine receptors in the brain, thereby reducing nausea and vomiting sensations. It is a suitable choice for treating severe vomiting in clients.

D) Simvastatin:
Simvastatin is a medication used to lower cholesterol levels and reduce the risk of cardiovascular events. It is not indicated for the treatment of vomiting and is unlikely to provide relief for this symptom.

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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 D

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Correct Answer is C

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