A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.
Which of the following findings should the nurse report to the provider immediately?
Respiratory rate 10/min.
Facial flushing.
Constipation.
Blood pressure 88/56 mm Hg.
The Correct Answer is A
Choice A rationale:
A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.
Choice B rationale:
Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.
Choice C rationale:
Constipation is a common side effect of morphine and can be managed with laxatives and diet.
Choice D rationale:
Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
Correct Answer is C
Explanation
Choice Arationale:
Flaxseed is a rich source of omega-3 fatty acids and can have anti-inflammatory effects. It does not have any known contraindications with SLE.
Choice B rationale:
Glucosamine is often used to support joint health. It is not contraindicated in clients with SLE and may actually provide some benefits in terms of reducing joint pain and stiffness.
Choice C rationale:
Echinacea is an herbal supplement that is often used to boost the immune system. However, in clients with autoimmune disorders like SLE, boosting the immune system can actually exacerbate the disease. Therefore, Echinacea is contraindicated in clients with SLE.
Choice Drationale:
Ginger is a common herbal supplement that is often used for its anti-inflammatory and anti-nausea effects. It does not have any known contraindications with systemic lupus erythematosus (SLE)
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