Which of these situations would cause the nurse to hold a dose of morphine?
The temperature is above 100.4 degrees Fahrenheit (38 degrees Celsius).
The blood pressure is above 140 mm Hg systolic.
Respiratory rate of 10 breaths per minute with an oxygen saturation level of 86%.
The heart rate is above 90 beats per minute.
The Correct Answer is C
A) Elevated temperature is not a typical reason to withhold morphine unless there are other concerns, such as infection.
B) Elevated blood pressure alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.
C) A respiratory rate of 10 breaths per minute with low oxygen saturation indicates respiratory depression, which is a significant concern and a reason to withhold morphine.
D) An elevated heart rate alone is not a reason to withhold morphine, but it should be considered in the context of the overall clinical picture.
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Related Questions
Correct Answer is D
Explanation
a) Taking the medication to prevent asthma attacks is an appropriate use and does not require immediate intervention.
b) Using the rescue inhaler twice a month may indicate the need for further evaluation but does not pose an immediate threat.
c) Sleep disturbances are a known side effect of leukotriene blockers and may need attention, but it is not an urgent concern.
d) Expressing suicidal ideation and having a plan for self-harm is a critical situation that requires immediate intervention to ensure the client's safety and well-being.
Correct Answer is C
Explanation
a) Insulin glargine is a long-acting basal insulin and is not typically administered before each meal.
b) Administering insulin glargine after meals is not the standard practice. It is given once daily to provide a continuous basal insulin level.
c) Insulin glargine is a once-daily basal insulin that is usually administered at the same time every day to maintain a consistent level of insulin in the body.
d) Unlike short-acting insulins, insulin glargine is not given with meals but provides a basal level of insulin throughout the day.
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