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 A
Explanation
Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.
Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.
Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.
Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect. Metabolic alkalosis would be indicated by an elevated pH and HCO3, but the PaCO2 would typically be higher due to compensatory hypoventilation.
Choice B reason: This is the correct choice. The elevated pH and low PaCO2 indicate respiratory alkalosis, likely due to hyperventilation. The normal HCO3 suggests that there has been no renal compensation, hence 'uncompensated'.
Choice C reason: This choice is incorrect because, for metabolic alkalosis to be uncompensated, the PaCO2 would typically be normal or high, not low.
Choice D reason: This choice is incorrect. Respiratory acidosis would be indicated by a low pH and high PaCO2, which is not the case here.
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