The nurse is preparing to administer an opioid agonist analgesic to the client.
Which of the following would be a priority assessment for the nurse to make once she has given the morphine?
Assess the client's skin for breakdown.
Assess the client's respiratory status.
Assess the client's urinary output.
Assess the client's abdominal sounds.
The Correct Answer is B
Choice A rationale
Assessing the client's skin for breakdown is important in general patient care, especially for immobile patients, but it is not a priority assessment directly related to the immediate physiological effects of administering an opioid analgesic like morphine. Skin integrity issues are typically a long-term complication.
Choice B rationale
Morphine, an opioid agonist, binds to mu-opioid receptors in the central nervous system, including the brainstem respiratory centers. This binding causes dose-dependent respiratory depression by decreasing the sensitivity of these centers to carbon dioxide, leading to reduced respiratory rate and depth. Normal respiratory rate is 12-20 breaths/min.
Choice C rationale
Opioids can cause urinary retention by increasing bladder sphincter tone and reducing detrusor muscle contractility, thereby impairing bladder emptying. While monitoring urinary output is important, respiratory depression is a more immediate and life-threatening adverse effect of opioid administration. Normal urinary output is 30-50 mL/hour.
Choice D rationale
Opioids commonly cause gastrointestinal side effects, including decreased gut motility, leading to constipation and reduced bowel sounds. While assessing abdominal sounds is relevant to monitor for ileus, respiratory depression poses a more acute and significant risk to patient safety following opioid administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A 15-degree angle is typically used for intradermal injections, where the medication is deposited just beneath the epidermis to form a bleb, not for subcutaneous injections which target the adipose tissue layer. Taut skin is also incorrect for subcutaneous.
Choice B rationale
For an average-sized client receiving a subcutaneous injection, a 45-degree angle facilitates optimal medication deposition into the subcutaneous adipose tissue layer. Pinching the skin helps to elevate the subcutaneous tissue away from underlying muscle, reducing the risk of intramuscular injection.
Choice C rationale
A 90-degree angle is typically used for intramuscular injections in most adults, aiming to deposit medication deep into muscle tissue. Stretching the skin is generally more appropriate for intramuscular injections rather than subcutaneous.
Choice D rationale
Z-tracking is a technique primarily used for intramuscular injections of irritating medications to prevent leakage back into subcutaneous tissue. It is not a standard technique for subcutaneous injections, which use a different angle and skin manipulation.
Correct Answer is D
Explanation
Choice A rationale
The abdomen, specifically 2 inches from the umbilicus, is a common site for subcutaneous injections due to the presence of ample adipose tissue, which allows for slower absorption of medications like insulin or heparin. Intradermal injections require a site with a thin epidermis and minimal subcutaneous tissue to ensure the medication remains within the dermal layer, making the abdomen unsuitable.
Choice B rationale
The anterior thigh is a common site for intramuscular injections, particularly in infants, due to the large muscle mass (vastus lateralis). While it can be used for subcutaneous injections, its muscularity and varying skin thickness make it less ideal for the precise shallow angle required for an intradermal injection, where the goal is to deposit the medication into the dermis.
Choice C rationale
The posterior upper arm, specifically the triceps area, is frequently utilized for subcutaneous injections, such as insulin or certain vaccines, because it offers sufficient subcutaneous tissue. However, similar to the anterior thigh, its anatomical characteristics with thicker skin and subcutaneous fat layers make it less optimal for the very superficial intradermal injection technique.
Choice D rationale
The upper chest, particularly below the clavicle and above the breasts, is an appropriate site for intradermal injections. This area, along with the inner forearm and upper back, has a thin epidermis and less subcutaneous tissue, which facilitates the proper placement of the medication within the dermis, allowing for the formation of a visible wheal, a key indicator of a successful intradermal injection.
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