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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. 0.45% sodium chloride: This is a hypotonic solution that helps lower serum sodium levels by diluting extracellular sodium and promoting cellular rehydration. It is commonly used to treat hypernatremia when there is no significant fluid volume overload.
B. 0.9% sodium chloride: This isotonic solution contains the same concentration of sodium as the blood. It does not correct hypernatremia and may worsen it if sodium levels are already elevated, especially in dehydrated clients.
C. Lactated Ringer's: While this is an isotonic fluid, it contains sodium and electrolytes that do not help reduce high serum sodium levels. It is more appropriate for fluid resuscitation than for treating hypernatremia.
D. 3% sodium chloride: This hypertonic solution is used for severe hyponatremia, not hypernatremia. Administering it to someone with elevated sodium levels would further increase sodium concentration and worsen the condition.
Correct Answer is A
Explanation
Rationale:
A. "Preventing readmissions will decrease overutilization of services.": Preventing avoidable hospital readmissions reduces repeated use of costly healthcare resources, improves patient outcomes, and avoids financial penalties tied to excessive readmissions.
B. "Hiring travel nurses is an effective method of cost containment.": While travel nurses fill staffing gaps, they often come at a higher cost due to agency fees, housing, and incentives. Relying on them long-term is generally not considered cost-effective.
C. "Purchasing more expensive items will improve quality health outcomes.": Higher cost does not always translate to better outcomes. Cost-effectiveness involves achieving the best results at the lowest possible cost, not simply spending more on supplies or equipment.
D. "Planning a 10-year budget will ensure cost-effective care.": Long-term planning is helpful, but health care demands and costs change rapidly. Effective cost management requires regular review and adjustment, not just extended projections.
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