A nurse is assessing a client prior to administering morphine. Which of the following findings indicates the nurse should withhold the morphine and contact the provider?
Urinary retention
Respiratory rate 16/min
Crackles in the lungs
Heart rate 68/min
The Correct Answer is C
C. Crackles in the lungs can indicate fluid accumulation, such as pulmonary edema or pneumonia. Morphine can exacerbate respiratory conditions by depressing the respiratory drive and increasing the risk of respiratory complications. Crackles in the lungs suggest potential pulmonary issues that may compromise respiratory function. The nurse should withhold morphine and contact the provider to assess the client's respiratory status and determine if further evaluation or treatment is needed before administering morphine.
A. Urinary retention is a potential side effect of morphine. However, it is not typically a reason to withhold morphine unless it is severe or accompanied by other concerning symptoms. The nurse should monitor urinary output and consider interventions to alleviate retention if necessary, but it may not require withholding morphine alone.
B. A respiratory rate of 16 breaths per minute is within the normal range for adults. However, the nurse should assess for any signs of respiratory distress, such as shallow breathing or decreased respiratory effort, which could indicate impending respiratory depression. If there are concerns about potential respiratory depression, the nurse should withhold morphine and notify the provider for further assessment.
D. Morphine can cause bradycardia as a side effect by depressing the cardiovascular system. A heart rate of 68 beats per minute is within the normal range for adults. However, the nurse should consider the client's baseline heart rate and any signs of hemodynamic instability. If the client shows signs of significant bradycardia or other concerning cardiovascular symptoms, withholding morphine and contacting the provider for further evaluation would be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. It promotes patient-centered care and acknowledges the client's right to make decisions about their own care, especially regarding end-of-life choices. This response supports ethical principles of autonomy and beneficence.
A. While obtaining power of attorney can be important for legal decision-making, this response may not address the emotional and supportive needs of the adult child or the family in this moment of distress and decision-making about end-of-life care.
B. It shows empathy and understanding of the adult child's feelings. However, it does not directly address the need to respect the client's wishes or provide guidance on how to navigate the situation practically.
D While it shows empathy, it may not fully address the needs of the adult child in terms of understanding and navigating the client's decision to discontinue treatment. The focus should be on supporting the family's emotional needs and facilitating communication about the client's wishes.
Correct Answer is A
Explanation
A. Lactated Ringer's is often preferred in the initial management of burn patients because it closely mimics the electrolyte composition of extracellular fluid and helps to restore intravascular volume and electrolyte balance. It provides effective fluid resuscitation without the risk of causing excessive free water retention or electrolyte imbalances.
B. This solution primarily provides free water and does not contain electrolytes. While it can be used to provide calories and some degree of hydration, it is not suitable as the sole fluid replacement for a client with major burns and dehydration. Using hypotonic solutions alone in burn patients can lead to dilutional hyponatremia and worsen electrolyte imbalances.
C. Similar to dextrose 5% in water, this solution provides some calories and minimal sodium chloride. However, it lacks sufficient electrolyte content to adequately replace losses in burn patients. It is not typically used as the primary fluid for resuscitation in major burns due to its inadequate electrolyte content.
D. Like the previous options, 0.45% sodium chloride solution does not provide adequate electrolyte support for fluid resuscitation in major burns. It may be used cautiously in specific situations where a more dilute sodium concentration is desired, but it is not suitable as the primary fluid replacement solution for burn patients experiencing dehydration.
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