A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

Hyperactive deep tendon reflexes

Fluid retention

Prolonged QT interval

Bradypnea

Answer and Explanation

The Correct Answer is D

Choice A reason: Hyperactive deep tendon reflexes are not linked to morphine toxicity. Morphine, an opioid, depresses the central nervous system, reducing reflexes. Hyperactive reflexes suggest neurological or stimulant effects, not opioid overdose, which primarily causes respiratory and consciousness depression in affected clients.
Choice B reason: Fluid retention is not a primary sign of morphine toxicity. Morphine may cause urinary retention via sphincter tone increase, but fluid overload is unrelated. Toxicity manifests as respiratory depression or sedation, driven by mu-opioid receptor overstimulation, not fluid balance alterations.
Choice C reason: Prolonged QT interval is associated with medications like antiarrhythmics, not morphine. Morphine toxicity primarily causes respiratory depression and sedation via central nervous system effects. Cardiac effects are rare, and QT prolongation is not a hallmark of opioid overdose in clinical settings.
Choice D reason: Bradypnea indicates morphine toxicity, as opioids depress the brainstem’s respiratory center via mu-receptor overstimulation. This slows breathing, risking hypoxia and respiratory arrest, a life-threatening complication requiring immediate intervention like naloxone to reverse opioid effects and restore normal respiratory function.

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Correct Answer is B

Explanation

Choice A reason: The lactation amenorrhea method is effective only up to 6 months postpartum, and only if exclusive breastfeeding and amenorrhea are maintained. It is not reliable for 12 months, so this statement is inaccurate, making it incorrect for contraception teaching.
Choice B reason: Placing the transdermal contraceptive patch on the upper arm or back ensures proper adhesion and absorption. This aligns with manufacturer guidelines for effective contraception, making it a correct and appropriate instruction for postpartum clients seeking reliable methods.
Choice C reason: A diaphragm used before pregnancy may no longer fit due to pelvic changes post-delivery. It requires refitting 6 weeks postpartum, so continuing use without adjustment is ineffective and risky, making this incorrect.
Choice D reason: Starting oral contraceptives immediately after delivery is not recommended, especially for breastfeeding mothers, due to risks like reduced milk supply or thromboembolism. Initiation typically begins 3-6 weeks postpartum, making this incorrect and unsafe.

A. Occasional mild nausea B. Swelling of the ankles in the evening C. Vaginal bleeding D. Increased appetite

Correct Answer is C

Explanation

Choice A reason: Occasional mild nausea is common in early pregnancy due to hormonal changes and does not typically require reporting unless severe or persistent. It is not a concerning finding at 14 weeks, so this is incorrect for urgent reporting.
Choice B reason: Mild ankle swelling in the evening can be normal due to fluid retention but is not urgent unless accompanied by other preeclampsia signs. It is less critical than bleeding, so this is incorrect for priority reporting.
Choice C reason: Vaginal bleeding at 14 weeks is abnormal and may indicate miscarriage, placental issues, or other complications, requiring immediate reporting to the provider for evaluation. This finding is critical at 14 weeks gestation, aligning with obstetric emergency protocols, making it the correct choice for teaching.
Choice D reason: Increased appetite is normal in pregnancy as nutritional needs rise and does not warrant urgent reporting. It reflects healthy adaptation rather than a complication, so this is incorrect for inclusion in teaching about concerning findings.

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A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is postpartum and interested in information about contraception. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

Correct Answer is C

Explanation

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