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 A
Explanation
Choice A rationale
The vastus lateralis muscle is the preferred intramuscular injection site for infants and children due to its large muscle mass and lack of major nerves or blood vessels, minimizing the risk of injury. This site is easily accessible and provides a safe area for medication absorption in developing musculature.
Choice B rationale
The ventrogluteal site is generally considered safe and effective for intramuscular injections, but it requires precise anatomical landmark identification, which can be challenging in infants and young children, increasing the risk of sciatic nerve injury if landmarks are not accurately identified.
Choice C rationale
The dorsogluteal site is contraindicated for intramuscular injections in infants and children due to the risk of sciatic nerve damage. The sciatic nerve runs through this area, and the muscle mass is not fully developed in younger patients, making it a hazardous site.
Choice D rationale
The deltoid muscle is too small and underdeveloped in infants and young children to safely accommodate intramuscular injections. Its limited muscle mass increases the risk of injury to underlying nerves and blood vessels, and absorption capacity is reduced.
Correct Answer is ["75"]
Explanation
Step 1 is 1.5 L × 1000 mL/L = 1500 mL.
Step 2 is 1500 mL ÷ 20 hours = 75 mL/hour.
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