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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.
Correct Answer is D
Explanation
A. Calcium Chloride: This is used to treat hypocalcemia, not hypercalcemia.
B. Spironolactone (Aldactone): This is a potassium-sparing diuretic, which does not affect calcium levels.
C. Kayexalate: This is used to treat hyperkalemia, not hypercalcemia.
D. Calcitonin: This is used to lower high serum calcium levels by inhibiting bone resorption and increasing calcium excretion.
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