A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?
Hypertension
Lacrimation
Tachycardia
Urinary retention
The Correct Answer is D
Choice A Reason:
Hypertension (high blood pressure) is not a common adverse effect of morphine. Opioid medications are more likely to cause hypotension (low blood pressure).
Choice B Reason:
Lacrimation (excessive tearing) is not a typical adverse effect of morphine. Opioids can cause dry mouth and decreased tear production.
Choice C Reason:
Tachycardia (rapid heart rate) is not a common adverse effect of morphine. Morphine and other opioids are more likely to cause bradycardia (slow heart rate) or a decrease in heart rate.
Choice D Reason:
Urinary retention is an adverse effect associated with opioid medications like morphine. Opioids can cause relaxation of smooth muscles, including those in the urinary bladder, which can lead to difficulty or inability to urinate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.
Choice B Reason:
Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.
Choice C Reason:
Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.
Choice D Reason:
This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.
Correct Answer is C
Explanation
Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.
Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.
Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.
Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.
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