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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
White bread is generally low in fiber and easy to digest, making it less likely to cause symptoms of dumping syndrome. While whole grains are typically healthier, in the case of dumping syndrome, low-fiber foods like white bread can be better tolerated.
Choice B reason:
Fresh apples should be avoided because they are high in fiber and can be difficult to digest, potentially exacerbating symptoms of dumping syndrome. The high fiber content can lead to rapid gastric emptying and increased symptoms such as cramping, bloating, and diarrhea.
Choice C reason:
Poached eggs are a good source of protein and are generally well-tolerated by individuals with dumping syndrome. They are easy to digest and do not contribute to rapid gastric emptying, making them a suitable food choice.
Correct Answer is D
Explanation
Choice A reason: Palpate the client’s pedal pulses
Palpating the client’s pedal pulses assesses the blood flow to the lower extremities but does not provide information about the client’s muscle strength. This action is important for evaluating circulation but is not relevant for determining strength.
Choice B reason: Ask the client how strong she feels today
Asking the client how strong she feels today provides subjective information about the client’s perception of her strength. While this can be useful, it does not offer an objective measure of muscle strength. Objective assessments are more reliable for determining the client’s actual strength.
Choice C reason: Ask the client to touch her finger to her nose
Asking the client to touch her finger to her nose assesses coordination and fine motor skills rather than muscle strength. This test is often used to evaluate neurological function but does not provide information about the strength of the muscles needed for ambulation.
Choice D reason: Ask the client to push her feet against the nurse’s palms
Asking the client to push her feet against the nurse’s palms is an effective way to assess the strength of the lower extremities. This action provides an objective measure of the client’s muscle strength, which is crucial for determining her ability to ambulate safely. This test helps the nurse evaluate whether the client has sufficient strength to stand and walk.
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