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.

Answer and Explanation

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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Correct Answer is ["A","C","D"]

Explanation

a. This statement warrants further education because enteric-coated aspirin is specifically designed to be absorbed in the small intestine and should not be chewed. Chewing the enteric coated aspirin can interfere with its protective coating and may lead to stomach irritation.

b. This statement is correct. Taking the aspirin with food can help minimize stomach irritation.

c. This statement warrants further education. Aspirin, even in low doses, should not be given to young children without consulting a healthcare provider due to the risk of Reye's syndrome.

d. This statement warrants further education. Ringing in the ears (tinnitus) is not a normal side effect of aspirin, and persistent symptoms should be reported to the healthcare provider.

e. This statement is correct. Black, tarry stools can indicate gastrointestinal bleeding, and the healthcare provider should be notified promptly.

A. Temperature of 101.2 degrees Fahrenheit B. Blood pressure of 144/68 mm Hg C. Glucose 128 mg/dl D. Heart rate of 102 beats per minute

Correct Answer is A

Explanation

a) An elevated temperature could indicate an infection, which is a serious concern in a client taking steroids, as steroids can suppress the immune system. This finding should be reported immediately.

b) Blood pressure within this range is generally acceptable and may not be a cause for immediate concern.

c) A glucose level of 128 mg/dl is within a reasonable range and may not require immediate reporting unless there are other concerning factors.

d) A heart rate of 102 beats per minute is generally within an acceptable range and may not be an immediate cause for concern in the absence of other symptoms.

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Which of these situations would cause the nurse to hold a dose of morphine?

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Naxlex Comprehensive Predictor Exams

A client has been prescribed 81 mg of enteric coated aspirin every morning. Which of these statements by the client warrants further education?

Correct Answer is ["A","C","D"]

Explanation

Which of these findings, from a client taking steroids, should the nurse report immediately?

Correct Answer is A

Explanation

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