Prior to the administration of morphine for a first day postoperative client who is experiencing severe pain, what action should the nurse perform first?

Assess vital signs

Assess bowel sounds

Listen to breath sounds

Determine the date of the client's last bowel movement

Answer and Explanation

The Correct Answer is A

A. Assess vital signs: Morphine is a potent opioid agonist that can cause life-threatening respiratory depression and hypotension. Establishing a baseline respiratory rate and blood pressure is the critical safety step before administration. This ensures the client can hemodynamically tolerate the CNS-depressant effects of the medication.

B. Assess bowel sounds: While opioids decrease gastrointestinal motility and can lead to paralytic ileus, this is a secondary concern compared to immediate respiratory safety. Assessing bowel sounds is part of a comprehensive post-operative exam but is not the priority action before analgesic administration.

C. Listen to breath sounds: Auscultating for adventitious sounds provides information about lung aeration, but the primary risk of morphine is a decrease in respiratory rate and depth. While important, it is less critical than the quantitative assessment of the respiratory rate and overall hemodynamic stability.

D. Determine the date of the client's last bowel movement: This information helps manage potential opioid-induced constipation, but it has no bearing on the immediate safety of administering an acute dose for severe pain. Pain management and respiratory monitoring take clinical precedence over bowel history in the early post-operative period.

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Correct Answer is ["A","B","C","D","E","F"]

Explanation

A. constipation. Reduced physical activity and the supine position decrease gastrointestinal peristalsis and the effectiveness of abdominal muscles used during defecation. This leads to prolonged colonic transit time and increased water absorption from fecal matter, resulting in hardened stools. It is a classic gastrointestinal complication of restricted mobility.

B. urinary retention. Immobility leads to a loss of gravity-aided bladder emptying and decreased detrusor muscle tone. The resulting urinary stasis increases the risk for both bladder distention and ascending infections due to incomplete voiding. This physiological alteration is common when clients are confined to a horizontal position.

C. disuse osteoporosis. The lack of weight-bearing stress on the skeletal system shifts the balance between osteoblast and osteoclast activity. Accelerated bone resorption leads to the leaching of calcium into the bloodstream, weakening the structural integrity of the trabecular bone. This metabolic change increases the risk for skeletal fragility.

D. hypostatic pneumonia. Prolonged recumbency results in the pooling of bronchial secretions in the dependent lobes of the lungs. Decreased chest expansion and diminished cough reflex prevent the effective clearance of these fluids, creating a medium for bacterial growth. This respiratory alteration significantly increases the risk of infection in immobile patients.

E. orthostatic hypotension. Immobility causes a reduction in the sensitivity of baroreceptors and a decrease in the efficiency of the skeletal muscle pump. When moving to an upright position, the cardiovascular system fails to constrict peripheral vessels adequately, leading to a sudden drop in blood pressure. This neurovascular maladaptation is a hallmark of prolonged bed rest.

F. a decrease in cardiac output and stroke volume. Prolonged bed rest leads to a reduction in total circulating blood volume and a subsequent decrease in venous return. The heart muscle may undergo slight atrophy, resulting in less forceful contractions and reduced volume ejected per beat. This cardiovascular decline limits the client's tolerance for physical exertion.

A. When should the nurse administer the medication? B. At bedtime C. As needed D. Before a meal E. With scheduled morning medications

Correct Answer is C

Explanation

A. At bedtime: Glipizide is a sulfonylurea that stimulates insulin secretion from the pancreatic beta cells. Administering this medication at bedtime without subsequent caloric intake would put the client at severe risk for nocturnal hypoglycemia. It is designed to manage postprandial glucose elevations rather than fasting levels during sleep.

B. As needed: Glipizide is a maintenance medication for Type 2 diabetes mellitus and is not intended for PRN or "as needed" use. It requires consistent daily dosing to maintain stable glycemic control and prevent hyperglycemia. Using it sporadically would result in erratic blood glucose fluctuations and poor metabolic management.

C. Before a meal: The abbreviation "ac" stands for the Latin "ante cibum," which translates to "before meals." Glipizide should typically be administered 30 minutes prior to a meal to allow the medication to stimulate insulin release in synchronization with food absorption. This timing effectively minimizes the risk of postprandial hyperglycemia.

D. With scheduled morning medications: While it may be given in the morning, the specific "ac" instruction takes precedence over a general morning schedule. If morning medications are given after breakfast, the glipizide would be less effective and potentially dangerous. The relationship to food intake is the critical factor for this secretagogue.

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Prior to the administration of morphine for a first day postoperative client who is experiencing severe pain, what action should the nurse perform first?

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