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

Answer and Explanation

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

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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

A. None B. Hypertonic C. Isotonic D. Hypotonic

Correct Answer is C

Explanation

Rationale-Blood is considered an isotonic solution because its solute concentration is similar to that of the cells in the body, allowing for free movement of water across cell membranes without causing a net influx or efflux of water. This isotonic nature is crucial for maintaining cell integrity and function.

Isotonic solutions have the same osmotic pressure as body’s plasma

B-Hypertonic solution like 3% saline have higher osmotic pressure compared to plasma. This type of solutions draw water from the cells causing shrinkage

D-Hypotonic solution like 0.45% saline have lower osmotic pressure as compared to plasma. They cause swelling of cells with eventual damage

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

Blood is what kind of solution?

Correct Answer is C

Explanation

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