A nursing student sees the nurse dip a pacifier in a sugar-water solution for an infant before administering an intramuscular injection. The nursing student asks why the nurse provided this sugar-water pacifier. The nurse’s appropriate response is: This will:

Choice A reason: This statement is true. Assessing mental status and level of consciousness is an important consideration for this treatment, as morphine can cause sedation, confusion, and respiratory depression. The nurse should monitor the client's orientation, alertness, and responsiveness, and use a sedation scale to evaluate the degree of sedation.

Choice B reason: This statement is true. Assessing urine output frequently is an important consideration for this treatment, as morphine can cause urinary retention, which can lead to bladder distension, infection, or kidney damage. The nurse should measure the client's urine output and check for signs of bladder fullness or discomfort.

Choice C reason: This statement is false. Monitoring potassium levels is not an important consideration for this treatment, as morphine does not affect the blood potassium level. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Potassium imbalance can be caused by other factors, such as diuretics, vomiting, diarrhea, or acid-base disorders.

Choice D reason: This statement is true. Teaching the family that only the client can press the button for pain medication is an important consideration for this treatment, as PCA Pump allows the client to self-administer a preset dose of morphine within a specified time interval. The family should not press the button for the client, as this can result in overmedication, overdose, or addiction.

Choice E reason: This statement is true. Ensuring there is an order for Naloxone in case of overdose is an important consideration for this treatment, as Naloxone is an antidote that can reverse the effects of morphine in the event of an overdose. Naloxone can restore the client's breathing, blood pressure, and consciousness, and prevent death.

Choice F reason: This statement is true. Assessing CO2 levels is an important consideration for this treatment, as morphine can cause respiratory depression, which can lead to hypercapnia, or high blood carbon dioxide level. Hypercapnia can cause headache, drowsiness, confusion, and coma. The nurse should monitor the client's respiratory rate, depth, and rhythm, and use a capnograph or a blood gas analysis to measure the CO2 level.

Choice A reason: This statement is false. Glucose: 88 mg/dL is a normal blood sugar level and does not indicate any problem with fluid or electrolyte balance¹.

Choice B reason: This statement is false. WBCs: 4000 is slightly below the normal range, but not significantly low. It may indicate a mild infection or inflammation, but not a serious fluid or electrolyte imbalance².

Choice C reason: This statement is false. K+: 3.4 mEq/L is slightly below the normal range, but not dangerously low. It may indicate a mild potassium deficiency, which can cause muscle weakness, but not restlessness or agitation.

Choice D reason: This statement is true. Na+: 154 mEq/L is above the normal range and indicates hypernatremia, or high blood sodium level. This can cause dehydration, confusion, restlessness, agitation, and seizures. It is a medical emergency that requires immediate treatment. Continuous tube feedings can increase the risk of hypernatremia if the formula is too concentrated or the fluid intake is inadequate⁵.