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?
Respirations deep at a rate of 10/min
Urinary output of 20 mL within 1 hr
Vomiting 30 mL of fluid
Blood pressure 90/60 mm Hg
The Correct Answer is A
A) Respirations deep at a rate of 10/min: This finding indicates respiratory depression, which is a significant concern with morphine administration. Respiratory depression can lead to hypoxia and respiratory arrest, posing a life-threatening situation for the client. Therefore, it is the priority finding that requires immediate intervention, such as reducing the dose of morphine, administering naloxone (an opioid antagonist), or providing respiratory support.
B) Urinary output of 20 mL within 1 hr: While decreased urinary output may indicate potential renal impairment or dehydration, it is not as immediately life-threatening as respiratory depression. However, it should still be monitored and addressed appropriately.
C) Vomiting 30 mL of fluid: Vomiting can be a side effect of morphine but may not require immediate intervention unless it leads to aspiration or dehydration. Nonetheless, it should be closely monitored for complications.
D) Blood pressure 90/60 mm Hg: Hypotension can occur as a side effect of morphine due to its vasodilatory effects. While low blood pressure should be addressed, it is not as immediately life-threatening as respiratory depression. Monitoring and appropriate interventions, such as fluid administration or adjusting the dose of morphine, can be implemented to manage hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) A child who recently received the human papillomavirus vaccine: There is no contraindication for administering the varicella vaccine to a child who recently received the human papillomavirus vaccine. These vaccines target different viruses and can typically be given concurrently without issue.
B) An older adult client living in a long-term care facility: Older adults living in long-term care facilities are at increased risk of complications from varicella infection and are, therefore, recommended to receive the varicella vaccine unless contraindicated due to specific health conditions.
C) A client who has AIDS: Clients with AIDS or other severe immunosuppressive conditions should not receive live virus vaccines like the varicella vaccine due to the risk of vaccine-induced disease. These individuals may have compromised immune systems, increasing the risk of adverse reactions or inadequate immune response to the vaccine.
D) A young adult who has an allergy to eggs: While some vaccines, including the varicella vaccine, are grown in eggs, having an allergy to eggs is not an absolute contraindication for receiving the vaccine. Most individuals with egg allergies can safely receive the varicella vaccine under medical supervision, as the risk of an allergic reaction is low.
Correct Answer is D
Explanation
A) Stroke volume: Stroke volume is the amount of blood ejected from the heart with each contraction, and it's an essential parameter in assessing cardiac function. However, when titrating a nitroprusside infusion, the primary goal is to manage blood pressure rather than directly targeting stroke volume. Nitroprusside is primarily used as a vasodilator to lower blood pressure in hypertensive emergencies. While changes in blood pressure may indirectly affect stroke volume, blood pressure itself is the primary parameter for titration.
B) Cardiac output: Cardiac output, which is the volume of blood pumped by the heart per minute, may be affected by nitroprusside due to its vasodilatory effects. However, like stroke volume, cardiac output is not typically the primary parameter for titrating a nitroprusside infusion. Blood pressure is a more direct indicator of the drug's effect on vascular tone and perfusion pressure.
C) Urine output: Monitoring urine output is crucial for assessing renal function and fluid status, but it is not the primary parameter used to titrate a nitroprusside infusion. While nitroprusside may affect renal blood flow and urine output indirectly, blood pressure remains the immediate indicator of the drug's hemodynamic effects.
D) Blood pressure: Nitroprusside is a potent vasodilator commonly used to lower blood pressure in hypertensive emergencies. Therefore, the primary assessment parameter for titrating a nitroprusside infusion is blood pressure. The nurse should monitor the client's blood pressure frequently and adjust the infusion rate accordingly to achieve the desired therapeutic effect while avoiding hypotension or excessive lowering of blood pressure.
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