A nurse is caring for a client who is receiving morphine via a PCA pump. The nurse should monitor for which of the following as adverse effects of this medication? Select all that apply

Tachycardia

Sedation

Hypotension

Hyperthermia

Bradypnea

Answer and Explanation

Correct Answer : B,C,E

Morphine is an opioid agonist that binds to mu-opioid receptors in the central nervous system to provide potent analgesia. Beyond pain relief, it exerts a depressant effect on the respiratory center and the autonomic nervous system, necessitating continuous monitoring of the patient's level of consciousness and hemodynamic stability.

Rationale:

A. Tachycardia is not a typical adverse effect of morphine; in fact, opioids tend to cause a decrease in heart rate or have no significant effect on it. Morphine reduces sympathetic outflow, which is more likely to result in bradycardia or a stable heart rate. The presence of tachycardia in a patient on a PCA pump might actually indicate inadequately controlled pain or a different underlying complication.

B. Sedation is a common and significant adverse effect of morphine that often precedes respiratory depression in patients using a PCA pump. The nurse must use a standardized scale to assess the client's arousal level, as excessive sleepiness indicates the drug is accumulating to potentially toxic levels. Monitoring for sedation allows the nurse to intervene early by adjusting the dose before life-threatening complications occur.

C. Hypotension occurs with morphine administration due to peripheral vasodilation and the release of histamine, which lowers systemic vascular resistance. This is particularly common when the drug is administered intravenously or in large doses via a PCA pump. The nurse must monitor blood pressure regularly and instruct the client to change positions slowly to prevent orthostatic hypotension and potential falls during therapy.

D. Hyperthermia is not an adverse effect associated with opioid analgesics like morphine. Morphine does not interfere with the thermoregulatory center in the hypothalamus in a way that would cause an elevated body temperature. If a patient receiving morphine develops a fever, the nurse should investigate other causes, such as an underlying infection or an inflammatory process, rather than attributing it to the medication.

E. Bradypnea, or an abnormally slow respiratory rate, is one of the most dangerous adverse effects of morphine because it directly depresses the brainstem respiratory centers. The nurse must count the client's respirations frequently and be prepared to administer naloxone if the rate falls below 8 to 10 breaths per minute. Bradypnea can lead to hypercapnia and respiratory arrest, making it a critical focus of PCA monitoring.

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Correct Answer is A

Explanation

Phenytoin is a hydantoin anticonvulsantthat stabilizes neuronal membranes by delaying the influx of sodium ions during action potentials. It has a narrow therapeutic indexand significant effects on cardiac conduction, specifically lengthening the refractory period. Due to its potential to depress myocardial automaticity, it is strictly avoided in patients with certain pre-existing conduction system abnormalities.

Rationale:

A.Sinus bradycardia is a major contraindication for phenytoin because the drug can further depress cardiac conduction and automaticity. Phenytoin possesses class IB antiarrhythmic properties, which can lead to severe cardiovascular collapse or heart block in patients with slow heart rates. Administering this drug to a bradycardic patient poses a life-threatening risk of asystole.

B.A history of cholecystitis, or inflammation of the gallbladder, does not contraindicate the use of phenytoin for seizure management. While phenytoin is metabolized by the liver, it does not have a direct impact on gallbladder function or the formation of gallstones. The nurse would prioritize monitoring liver enzymes rather than focusing on a history of cholecystitis.

C.Taking vitamin B12 supplements does not prevent a patient from receiving phenytoin, as there is no dangerous interaction between the two. Interestingly, long-term phenytoin use is actually associated with folate deficiency rather than issues with B12. Supplements are generally safe and may be necessary for patients with concurrent nutritional deficiencies during anticonvulsant therapy.

D.Ibuprofen is a non-steroidal anti-inflammatory drug that does not have a documented clinical contraindication with the administration of phenytoin. While phenytoin has many drug-drug interactions involving the cytochrome P450 system, ibuprofen is not typically one that causes toxicity. The nurse can safely administer both medications as long as standard monitoring is performed.

A. Capillary refill less than 2 seconds B. Peaked T-waves on client's cardiac rhythm strip C. Client report of constipation D. Blood pressure 96/80 mm Hg

Correct Answer is B

Explanation

Potassium chloride is an electrolyte replenisherused to resolve hypokalemia, a state where serum potassium levels fall below 3.5 mEq/L. Potassium is essential for maintaining the resting membrane potentialof excitable tissues. Correcting deficits requires precise dosing, as overcorrection leads to hyperkalemia, causing lethal cardiac conduction abnormalities and potential asystole.

Rationale:

A.A capillary refill time of less than 2 seconds is a normal clinical finding indicating adequate peripheral perfusion and cardiac output. This result suggests that the client’s circulatory status is currently stable and does not indicate an adverse reaction to the potassium chloride therapy. Therefore, the nurse does not need to report this specific finding to the healthcare provider.

B.Peaked T-waves are a classic electrocardiographic sign of hyperkalemia, indicating that the potassium replacement therapy may have overcorrected the initial deficit. High serum potassium levels accelerate repolarization, which can quickly transition into dangerous arrhythmias like ventricular fibrillation. This is a critical safety finding that requires immediate notification to the provider to prevent cardiac arrest and adjust the medication.

C.Constipation is a common symptom associated with the initial state of hypokalemia due to decreased smooth muscle motility in the gastrointestinal tract. While the nurse should monitor bowel function, a report of constipation is expected with the underlying diagnosis and is not a priority for reporting. Effective potassium replacement should eventually help restore normal peristalsis and resolve this specific symptom.

D.A blood pressure of 96/80 mm Hg is slightly low but is not the most urgent finding when evaluating the safety of potassium chloride administration. While the nurse should monitor hemodynamics, the immediate threat posed by potassium imbalances is related to cardiac rhythm rather than modest blood pressure fluctuations. Peaked T-waves represent a more direct and fatal complication of electrolyte mismanagement.

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A nurse is caring for a client who is receiving morphine via a PCA pump. The nurse should monitor for which of the following as adverse effects of this medication? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record for a client who has a new prescription for phenytoin. Which of the following statements from the medical record should the nurse identify as a contraindication for the administration of phenytoin?

Correct Answer is A

Explanation

A nurse is assessing a client who has hypokalemia and a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

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