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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Metabolic acidosis is characterized by a low pH and a low HCO3. However, George's HCO3 is within normal range, indicating that metabolic acidosis is not the primary issue.
Choice B reason: Partially compensated metabolic acidosis would present with a low pH and a low HCO3, along with a low PaCO2 as the body attempts to compensate. George's PaCO2 is elevated, which is not consistent with this condition.
Choice C reason: George's high PaCO2 and near normal HCO3 suggest that his primary issue is respiratory acidosis. The body has begun to compensate by retaining HCO3, making it partially compensated.
Choice D reason: Uncompensated respiratory acidosis would present with an elevated PaCO2 and a normal HCO3. Since George's HCO3 is elevated, it indicates partial compensation.
Correct Answer is D
Explanation
Choice A reason: Dependent rubor, a reddish coloration of the skin that occurs when the legs are in a dependent position, can be a sign of PAD, indicating poor arterial flow.
Choice B reason: Foot ulcers may occur in individuals with PAD due to poor blood circulation and the inability of sores or injuries to heal properly.
Choice C reason: Rest pain is a symptom of advanced PAD and occurs due to insufficient blood flow to the limbs even at rest, often worsening at night when the legs are elevated.
Choice D reason: Intermittent claudication, characterized by pain and cramping in the legs during exercise that disappears after rest, is a hallmark symptom of PAD and results from inadequate blood flow during increased activity.
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