A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Tell the client he can no longer have any more pain medication

Notify the prescribing physician

Administer half the dose of morphine, 2 mg IV

Administer 4 mg of morphine IV as ordered

Answer and Explanation

The Correct Answer is B

A. Tell the client he can no longer have any more pain medication: This is not appropriate. The client’s severe pain needs to be managed, but the current vital signs suggest a need for careful evaluation before administration.
B. Notify the prescribing physician: This is the correct choice. The client's blood pressure and respiratory rate are significantly low, which could be exacerbated by morphine. The physician needs to be informed to reassess pain management and possibly adjust the treatment.
C. Administer half the dose of morphine, 2 mg IV: Given the client's low blood pressure and respiratory rate, any morphine administration could worsen these issues. Adjusting the dose without physician guidance is not appropriate.
D. Administer 4 mg of morphine IV as ordered: Administering the full dose without addressing the client’s low blood pressure and respiratory rate could lead to severe complications.

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Correct Answer is D

Explanation

A. Blood in the tubing close to the insertion site: This indicates a possible issue with the IV but not fluid overload specifically.
B. Chills, fever, and generalized discomfort: These symptoms may suggest an infection or reaction but are not specific to fluid overload.
C. Pallor, sweating, and discomfort at the insertion site: These could indicate a local reaction or issue with the IV site but not fluid overload.
D. Dyspnea, headache, and increased blood pressure: These symptoms are indicative of fluid overload, as the body reacts to excessive fluid with symptoms such as difficulty breathing (dyspnea), increased blood pressure, and headaches.

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr B. Elevate the feet and lower the head C. Call the surgeon and report the vital signs D. Monitor the vital signs every 15 minutes

Correct Answer is B

Explanation

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

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A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Correct Answer is D

Explanation

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Correct Answer is B

Explanation

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