A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications.

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for developing

dropdown

due to

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.

Choice A rationale

Injecting air into the ampule prior to drawing the medication into a syringe can cause the medication to spill and is not a safe practice.

Choice B rationale

Adding 0.5 mL of diluent to the medication is not a standard procedure for medication administration from an ampule and can lead to incorrect dosing.

Choice C rationale

Using a filter needle to aspirate the medication is important to prevent glass particles from the broken ampule from entering the syringe and being administered to the patient.

Choice D rationale

Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary, as the medication is already inside the sealed ampule, and it can increase the risk of contamination.

Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.

Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.

Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.

Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.