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?

Choice A reason:

The statement “Reposition the client a second time before assessing his respirations” is not appropriate in this scenario. If the client remains apneic after the initial airway repositioning, further repositioning is unlikely to be effective. Immediate action is required to determine the next steps in care.

Choice B reason:

The statement “Place a red tag on the client’s upper body and obtain immediate help from other personnel” is incorrect. A red tag is used for patients who require immediate medical attention and have a chance of survival with timely intervention. Since the client remains apneic despite airway repositioning, they are unlikely to survive without immediate advanced medical intervention, which may not be feasible in a mass casualty situation.

Choice C reason:

The statement “Place a black tag on the client’s upper body and attempt to help the next client in need” is correct. In a mass casualty incident, a black tag is used to indicate that a patient is deceased or expected to die due to the severity of their injuries and the lack of available resources to provide the necessary care. Since the client remains apneic with a weak pulse, they are unlikely to survive, and resources should be directed to those with a higher chance of survival.

Choice D reason:

The statement “Start CPR” is not the most appropriate action in this scenario. In a mass casualty situation, resources must be allocated to those who have the best chance of survival. Starting CPR on a client who remains apneic despite airway repositioning may not be the best use of limited resources, especially when other clients may need immediate attention and have a higher chance of survival.

Choice A reason:

Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.

Choice B reason:

Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.

Choice C reason:

Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.

Choice D reason:

Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.