A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?
Prolonged QT interval
Fluid retention
Bradypnea
Hyperactive deep tendon reflexes
The Correct Answer is C
Rationale:
A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.
B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.
C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.
D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Tachypnea: An increased respiratory rate is not commonly associated with epidural anesthesia and is not a typical adverse effect. It may result from anxiety or pain but does not directly indicate a problem with the epidural.
B. Hyperreflexia: Epidurals often reduce sensation and reflexes, not heighten them. Hyperreflexia is not expected and would not be a direct adverse effect of epidural administration during labor.
C. Hypothermia: While mild temperature changes may occur, hypothermia is not a common or significant adverse effect of epidural anesthesia. It is not typically monitored as a key complication.
D. Hypotension: Epidural anesthesia can cause vasodilation by blocking sympathetic nerve fibers, leading to a drop in maternal blood pressure. This is a well-known and common adverse effect requiring close monitoring and potential intervention.
Correct Answer is B
Explanation
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.
B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.
C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.
D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.
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