A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect f the medication?
Respiratory rate 8/min
sa02 94%
Pain level of 6 on a scale from 0 to 10
Sleepy, but arousing when her name is called
The Correct Answer is A
Morphine sulfate, an opioid analgesic, can cause serious side effects including lifethreatening respiratory depression. A normal respiratory rate for adults is typically between 12 to 16 breaths per minute. A rate of 8 breaths per minute is considered abnormally low and can be indicative of respiratory depression, which is a serious risk associated with opioid medications like morphine sulfate. It's important for healthcare providers to monitor clients closely after administering opioids to manage any potential adverse effects promptly.
B-SaO2 is not a direct indicator of central respiratory depression
C-Pain relief is expected as it is an analgesic
D-Morphine can cause sedation which is okay after respiratory depression has been ruled out
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale- the most appropriate action for a nurse to plan would be to increase the client's fluid intake. This action helps to restore the fluid volume in the body, thereby improving blood pressure levels.
Proper hydration is crucial in dehydrated and hypotensive clients.
B- The Valsalva maneuver is not typically recommended for hypotension as it can further decrease blood pressure.
C- Elevating the head of the bed is generally advised for clients with respiratory issues, not primarily for those with hypotension. Guided imagery can be a useful tool for relaxation but does not directly address the immediate physiological needs of dehydration and hypotension.
D- Relaxation does not solve the client’s issues
Correct Answer is C
Explanation
Rationale-Nonnutritive sugar substitute produces a sweet taste without contributing any calories. For a client with type 1 diabetes mellitus, the best recommendation for a sweetener would be a nonnutritive sugar substitute. These substitutes are considered safe and do not affect blood sugar levels, which is crucial for managing diabetes. They include aspartame, sucralose, and stevia, offer sweetness without the additional calories and carbohydrates, making them a suitable choice for individuals with diabetes. Natural honey and corn syrup, while natural, are high in carbohydrates and can cause an increase in blood sugar levels. This interferes with the titration of insulin and should be avoided.
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