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 not grimacing
The client has an elevated heart rate
The Correct Answer is C
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Change the perineal pad with each void.
Rationale:
A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.
B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.
C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.
D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.
Correct Answer is C
Explanation
c. Dispose of the used needle immediately in a sharps container.
The nurse should dispose of the used needle immediately in a sharps container to reduce the risk of a needlestick injury. Sharps containers are specifically designed for the safe disposal of needles and other sharp objects. By placing the used needle directly into a sharps container, the nurse eliminates the need for handling or manipulating the needle further, reducing the risk of accidental needlestick injuries.
Explanation for the other options:
a. Place a cap holder securely on the used needle before disposal: Cap holders are not recommended for securing used needles before disposal. They may not provide adequate protection against needlestick injuries and can potentially increase the risk of accidental needlesticks when atempting to secure the cap holder.
b. Recap the needle for disposal later: Recapping the needle increases the risk of a needlestick injury. It is generally not recommended to recap needles after use, as it poses a greater risk of accidental puncture.
d. Detach the used needle and dispose of it promptly: Detaching the needle from the syringe before disposal is not recommended, as it increases the risk of a needlestick injury. It is safer to dispose of the needle and syringe as a unit in a sharps container to minimize the risk of accidental puncture.
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