A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

The client's blood pressure has been reduced.

The client exhibits diaphoresis.

The client is grimacing.

The client has an elevated heart rate.

Answer and Explanation

The Correct Answer is A

A.   This is the correct answer. Reduction in blood pressure is a common therapeutic response to morphine administration. Morphine acts as a vasodilator, which can lead to decreased blood pressure.
B.   Diaphoresis, or sweating, is not necessarily a therapeutic response to morphine. It may indicate other physiological responses or side effects.
C.   Grimacing suggests pain or discomfort, which is not a therapeutic response but rather an indication that the pain relief from morphine may not be sufficient.
D.   An elevated heart rate is not typically a therapeutic response to morphine and may indicate pain, anxiety, or other factors.

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Correct Answer is D

Explanation

- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.

A. A client who has a history of pancreatitis and reports severe abdominal pain B. A client who has heart failure and reports severe dyspnea C. A client who is scheduled for abdominal surgery in 1 hr D. A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Correct Answer is B

Explanation

A. While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B. Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C. While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D. While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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