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: Eating a snack half an hour before playing soccer is a good practice for children with type 1 diabetes. Physical activity can lower blood glucose levels, and having a snack beforehand helps prevent hypoglycemia. This statement indicates that the child understands the importance of managing blood glucose levels during exercise.
Choice B reason: My morning blood glucose should be between 90 and 130 is a correct statement regarding target blood glucose levels for children with type 1 diabetes. However, this statement alone does not indicate a comprehensive understanding of diabetes management, as it only addresses one aspect of blood glucose monitoring.
Choice C reason: I should not take my regular insulin when I am sick is incorrect. Children with type 1 diabetes should continue taking their insulin even when they are sick, as illness can cause blood glucose levels to rise. They may need to adjust their insulin dosage, but stopping insulin altogether can lead to dangerous complications like diabetic ketoacidosis.
Choice D reason: I can store unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, not the freezer. Freezing insulin can damage its effectiveness. Unopened insulin should be kept at a temperature between 36°F and 46°F (2°C to 8°C).
Correct Answer is C
Explanation
Choice A reason:
Urinary hesitancy, while concerning, is not typically an immediate threat to the client’s health. It can indicate underlying issues such as benign prostatic hyperplasia (BPH) or urinary tract infections, which require medical attention but are generally not life-threatening. Addressing urinary hesitancy is important, but it does not take precedence over more acute conditions.
Choice B reason:
Swollen gums can be a sign of poor oral hygiene, gingivitis, or other dental issues. While important to address, swollen gums are not usually an immediate threat to the client’s overall health. Dental issues can lead to complications if left untreated, but they do not typically require urgent intervention.
Choice C reason:
Dysphagia, or difficulty swallowing, is a priority because it can lead to serious complications such as aspiration pneumonia, malnutrition, and dehydration. Aspiration pneumonia occurs when food or liquid enters the lungs, leading to infection. Dysphagia can also cause significant discomfort and impact the client’s ability to eat and drink adequately, making it a critical issue to address promptly.
Choice D reason:
Pruritus, or itching, can be a symptom of various conditions, including allergies, skin disorders, or systemic diseases such as liver or kidney problems. While pruritus can be very uncomfortable and impact the client’s quality of life, it is not typically an immediate threat to health. It requires assessment and management but is not as urgent as dysphagia.
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