A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Sleepy, but arousing when the name is called.
Pain level of 6 on a scale from 0 to 10.
Respiratory rate of 8/min.
SaO2 94%
The Correct Answer is C
Choice A: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.
Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.
Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.
Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.
Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.
Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.
Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.
Correct Answer is D
Explanation
Choice A reason: Humidifying the client's room can help maintain mucous membrane integrity and prevent respiratory infections, which is crucial for a client with a low WBC count.
Choice B reason: Replacing the water in flower vases daily can prevent the growth of bacteria, reducing the risk of infection for an immunocompromised client.
Choice C reason: Cleaning dentures in a denture cup is a standard infection control practice that helps maintain oral hygiene and prevent infections.
Choice D reason: Serving cooked fruit with meals reduces the risk of transmitting infections that can be associated with raw fruits, which is important for a client with neutropenia.
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