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: I would be happy to do whatever I can to help you. While this response shows empathy and a willingness to help, it does not address the fact that shopping for the client is outside the nurse’s job description. It is important for the nurse to adhere to professional boundaries and find appropriate solutions within those limits.

Choice B reason: What I think you should do is wait for the days when you feel better and do your grocery shopping then. This response is not practical or supportive. It does not provide a solution for the client’s immediate needs and may come across as dismissive of her current difficulties.

Choice C reason: I won’t be able to shop for you today because I have to get home to my family. This response is honest but lacks empathy and does not offer any alternative solutions. It may leave the client feeling unsupported and frustrated.

Choice D reason: Let’s look at some other resources to solve this problem. This response is the most appropriate as it acknowledges the client’s needs and seeks to find a solution within the nurse’s professional boundaries. The nurse can help the client explore options such as grocery delivery services, community resources, or assistance from family and friends.

A. Weigh the client daily. B. Monitor the client for signs of bleeding. C. Monitor the client’s respirations every 4 hours. D. Administer an antacid with the medication to decrease nausea.

Correct Answer is A

Explanation

Choice A reason: Weigh the client daily is important because chlorpromazine can cause weight gain as a side effect. Regular monitoring of the client’s weight helps in managing and mitigating this potential adverse effect.

Choice B reason: Monitor the client for signs of bleeding is not typically necessary for clients taking chlorpromazine. This medication does not commonly cause bleeding issues. Monitoring for bleeding would be more relevant for clients on anticoagulants or medications that affect platelet function.

Choice C reason: Monitor the client’s respirations every 4 hours is not specifically required for clients on chlorpromazine. While respiratory depression can be a concern with some medications, it is not a common side effect of chlorpromazine.

Choice D reason: Administer an antacid with the medication to decrease nausea is not recommended. Antacids can interfere with the absorption of chlorpromazine, reducing its effectiveness. If the client experiences nausea, other antiemetic strategies should be considered.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

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