A patient receiving Morphine for postoperative pain relief displays slow, shallow breathing with a rate of 8 breaths/minute. The nurse recognizes this as a side effect called:
Miosis
Sedation
Respiratory depression
Euphoria
The Correct Answer is C
Choice A reason: This is incorrect. Miosis is the constriction of the pupils, which can also be caused by morphine, but it is not a life-threatening side effect. Miosis occurs because morphine stimulates the parasympathetic nervous system, which controls the muscles that constrict the pupils¹.
Choice B reason: This is incorrect. Sedation is the state of being calm, relaxed, and sleepy, which can also be caused by morphine, but it is not a life-threatening side effect. Sedation occurs because morphine depresses the central nervous system, which reduces the activity of the brain and the body.
Choice C reason: This is correct. Respiratory depression is the slowing down of breathing, which can be a life-threatening side effect of morphine. Respiratory depression occurs because morphine depresses the respiratory center in the brainstem, which regulates the rate and depth of breathing. If the breathing becomes too slow or shallow, the patient may not get enough oxygen and may lose consciousness or die.
Choice D reason: This is incorrect. Euphoria is the feeling of intense happiness, pleasure, or wellbeing, which can also be caused by morphine, but it is not a life-threatening side effect. Euphoria occurs because morphine stimulates the reward system in the brain, which releases dopamine, a neurotransmitter that causes positive emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Dextromethorphan (Robitussin) is not the correct medication for a patient with a productive cough. Dextromethorphan is a cough suppressant that works by acting on the brain to reduce the cough reflex. Dextromethorphan is used for a dry, nonproductive cough that is caused by irritation or inflammation. Dextromethorphan is not effective for a productive cough that produces mucus, and it may even be harmful by preventing the clearance of secretions from the lungs.
Choice B reason: Fluticasone (Flonase) is not the correct medication for a patient with a productive cough. Fluticasone is a corticosteroid that works by reducing inflammation and swelling in the nasal passages. Fluticasone is used for allergic rhinitis, which is a condition that causes sneezing, itching, and runny nose due to an allergic reaction. Fluticasone is not effective for a productive cough that produces mucus, and it may even worsen it by suppressing the immune system and increasing the risk of infection.
Choice C reason: Pseudoephedrine (Sudafed) is not the correct medication for a patient with a productive cough. Pseudoephedrine is a decongestant that works by constricting the blood vessels in the nasal passages and sinuses. Pseudoephedrine is used for nasal congestion, which is a condition that causes stuffy nose and difficulty breathing due to swelling of the mucous membranes. Pseudoephedrine is not effective for a productive cough that produces mucus, and it may even cause side effects such as increased blood pressure, insomnia, and anxiety.
Choice D reason: Guaifenesin (Mucinex) is the correct medication for a patient with a productive cough. Guaifenesin is an expectorant that works by thinning and loosening the mucus in the chest and throat. Guaifenesin is used for a productive cough that produces mucus, as it helps the cough to be more effective and clear the airways. Guaifenesin is generally safe and well tolerated, but it may cause some minor side effects such as nausea, vomiting, and headache.
Correct Answer is A
Explanation
Choice A reason: This is correct. Blood pressure is the most important vital sign to monitor after giving sublingual nitroglycerin to a client with chest pain. Nitroglycerin is a medication that dilates the blood vessels and lowers the blood pressure. This can relieve the chest pain caused by angina, which is a condition where the heart muscle does not get enough oxygen due to narrowed or blocked arteries. However, if the blood pressure drops too low, the client may experience dizziness, fainting, or shock. Therefore, the nurse should check the blood pressure before and after giving nitroglycerin and report any significant changes to the doctor.
Choice B reason: This is incorrect. Blood glucose levels are not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have diabetes, which is a risk factor for heart disease. Diabetes is a condition where the body cannot regulate the amount of sugar in the blood. High or low blood sugar levels can cause symptoms such as thirst, hunger, fatigue, blurred vision, or confusion. Therefore, the nurse should check the blood glucose levels of clients with diabetes and follow the doctor's orders for managing their blood sugar.
Choice C reason: This is incorrect. Body temperature is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have a fever, which is a sign of infection or inflammation. Fever is a condition where the body's temperature rises above the normal range. Fever can cause symptoms such as sweating, chills, headache, or muscle ache. Therefore, the nurse should check the body temperature of clients with fever and follow the doctor's orders for treating their infection or inflammation.
Choice D reason: This is incorrect. Respiratory rate is not directly affected by sublingual nitroglycerin. However, some clients with chest pain may also have difficulty breathing, which is a sign of heart failure or lung disease. Difficulty breathing is a condition where the client cannot get enough air into or out of the lungs. Difficulty breathing can cause symptoms such as coughing, wheezing, or gasping. Therefore, the nurse should check the respiratory rate of clients with difficulty breathing and follow the doctor's orders for improving their oxygenation.
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