The nurse is caring for a client admitted with moderate neck pain and numbness and tingling in the lower extremities after falling off a trampoline. The client is alert, oriented, with spontaneous movement of all extremities, respiratory rate of 16 breaths per minute and regular, heart rate of 96 beats per minute, and blood pressure of 124/76 mmHg. What action should the nurse take?

Choice A reason: Increasing morphine without monitoring risks respiratory depression, especially in an unresponsive patient. Titrating with a respiratory rate limit is safer, making this incorrect, as it lacks safeguards compared to the nurse’s best intervention to manage pain and avoid complications.

Choice B reason: Increasing the morphine drip to relieve grimacing while monitoring for a respiratory rate below 10 breaths/min balances pain control and safety. This aligns with palliative care protocols, making it the correct intervention for the nurse to manage the patient’s discomfort effectively.

Choice C reason: Decreasing morphine and switching to Versed may not address pain and risks withdrawal. Titrating morphine is more appropriate, making this incorrect, as it’s less effective than the nurse’s focus on maintaining pain relief while monitoring respiratory status.

Choice D reason: Asking the family to leave doesn’t address the patient’s pain or ventilator resistance. Adjusting morphine is the priority, making this incorrect, as it’s irrelevant compared to the nurse’s intervention to manage the patient’s discomfort and sedation needs.

Choice A reason: Initiating antibiotics is critical but follows cultures to identify the causative organism. Obtaining cultures first ensures accurate treatment, making this incorrect, as it risks altering culture results if antibiotics are given before sampling in the pneumonia client.

Choice B reason: Obtaining blood and sputum cultures first identifies the pneumonia-causing organism, guiding effective antibiotic therapy. This aligns with infection management protocols, making it the correct initial order to implement for the client admitted with pneumonia to ensure accurate treatment.

Choice C reason: Airborne precautions are needed for specific pneumonias (e.g., tuberculosis), but most require droplet precautions. Cultures guide treatment, making this incorrect, as it’s less urgent than obtaining cultures first to confirm the pathogen in the client with pneumonia.

Choice D reason: An indwelling catheter is unnecessary for pneumonia unless urinary retention is present. Obtaining cultures is the priority, making this incorrect, as it’s irrelevant to the immediate management of the client’s infection compared to identifying the causative organism.