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 A
Explanation
Choice A reason:
The statement “Provide bedtime rituals” is correct. Establishing a consistent bedtime routine can help toddlers feel more secure and relaxed, which can promote better sleep. Bedtime rituals might include reading a story, singing a lullaby, or having a warm bath before bed. These activities signal to the child that it is time to wind down and prepare for sleep.
Choice B reason:
The statement “Encourage play exercises in the evening” is incorrect. While physical activity is important for overall health, engaging in stimulating play exercises right before bedtime can make it harder for toddlers to settle down and fall asleep. It is better to encourage quiet, calming activities in the evening.
Choice C reason:
The statement “Explain the source of the toddler’s fears” is not the most effective approach for promoting sleep. While addressing fears is important, the explanation alone may not be sufficient to help the toddler feel secure enough to sleep. Providing comfort and reassurance through bedtime rituals is more effective in creating a sense of safety.
Choice D reason:
The statement “Turn off the room light” is partially correct but not the best standalone solution. While a dark environment can promote sleep, some toddlers may feel more secure with a nightlight. The focus should be on creating a calming and comfortable sleep environment, which includes but is not limited to adjusting the lighting.
Correct Answer is D
Explanation
Choice A reason: Implement a resolution
Implementing a resolution without first understanding the root cause of the conflict can lead to ineffective solutions and may not address the underlying issues. It is essential to identify the problem first to ensure that any resolution is appropriate and effective.
Choice B reason: Evaluate the results
Evaluating the results is an important step in the conflict resolution process, but it comes after implementing a solution. Before any evaluation can take place, the problem must be identified, and a resolution must be implemented. Therefore, this step is not the first action to take.
Choice C reason: Brainstorm solutions
Brainstorming solutions is a critical part of resolving conflicts, but it should occur after the problem has been clearly identified. Without a clear understanding of the problem, brainstorming may not yield effective solutions. Identifying the problem ensures that the brainstorming session is focused and productive.
Choice D reason: Identify the problem
Identifying the problem is the first and most crucial step in resolving any conflict. Understanding the root cause of the conflict between the pharmacy and the staff nurses will provide a clear direction for developing effective solutions. This step involves gathering information, listening to all parties involved, and pinpointing the specific issues that need to be addressed.
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