A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Sleepy, but arousing when her name is called.

Respiratory rate 8/min.

Pain level of 6 on a scale from 0 to 10.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.

Choice B reason:

A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.

Choice C reason:

A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.

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Correct Answer is D

Explanation

Choice A reason:

Washing the cord daily with mild soap and water is not recommended. The best practice is to keep the umbilical cord stump clean and dry. Cleaning it with water and mild soap can be done if it gets dirty, but it should not be a daily routine as it might delay the drying process.

Choice B reason:

Applying petroleum jelly to the cord stump is not advised. The goal is to keep the stump dry to promote natural drying and falling off. Petroleum jelly can keep the area moist, which is counterproductive to the drying process.

Choice C reason:

Covering the cord with the diaper is not recommended. Instead, the diaper should be folded down below the umbilical cord stump to keep it exposed to air and prevent irritation from urine or stool3. This helps the stump to dry out and fall off naturally.

Choice D reason:

Giving a sponge bath until the cord stump falls off is the correct instruction. Submerging the baby in water can delay the drying and falling off of the stump. Sponge baths help keep the area dry and clean, promoting faster healing.

A. Low-protein, low-potassium diet B. Regular diet, no added salt C. Low-carbohydrate, low-protein diet D. Low-sodium, fluid-restricted diet

Correct Answer is D

Explanation

Choice A reason: Low-protein, low-potassium diet

A low-protein, low-potassium diet is not typically recommended for acute glomerulonephritis. While protein intake may need to be moderated to reduce the workload on the kidneys, potassium restriction is usually not necessary unless there is hyperkalemia (high potassium levels) present. The primary dietary focus should be on managing fluid and sodium intake to control edema and hypertension.

Choice B reason: Regular diet, no added salt

A regular diet with no added salt is a step in the right direction but may not be sufficient for managing acute glomerulonephritis with significant edema. Sodium restriction is crucial to help reduce fluid retention and control blood pressure. Therefore, a more stringent low-sodium diet is often necessary.

Choice C reason: Low-carbohydrate, low-protein diet

A low-carbohydrate, low-protein diet is not appropriate for managing acute glomerulonephritis. Carbohydrate intake does not directly impact kidney function in this context, and protein intake should be moderated rather than severely restricted. The focus should be on sodium and fluid management.

Choice D reason: Low-sodium, fluid-restricted diet

A low-sodium, fluid-restricted diet is the most appropriate choice for a client with acute glomerulonephritis and peripheral edema. Reducing sodium intake helps to minimize fluid retention and control blood pressure, while fluid restriction helps to prevent further edema and manage the workload on the kidneys. This dietary approach is essential for managing the symptoms and complications associated with acute glomerulonephritis.

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A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

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