A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?
Pupil diameter 6 mm
Blood pressure 80/40 mm Hg
Urinary output 120 mL/4 hr
Bowel movement 5 days ago
The Correct Answer is B
Rationale:
A. Pupil diameter 6 mm: Dilated pupils may indicate CNS stimulation or sensitivity, but this finding is less immediately life-threatening than significant hypotension. Pupil size should still be monitored, especially for signs of overdose or neurologic changes.
B. Blood pressure 80/40 mm Hg: Severe hypotension is a critical adverse effect of IV morphine that can compromise perfusion to vital organs. It requires immediate attention to prevent shock, making this the highest priority finding to report.
C. Urinary output 120 mL/4 hr: While this output is slightly below normal, it does not yet indicate acute kidney injury. Continued monitoring is warranted, but it is not the most urgent issue compared to hypotension.
D. Bowel movement 5 days ago: Constipation is a common side effect of opioids, but it typically develops gradually and can be managed with bowel protocols. It is not as urgent as hypotension and can be addressed after stabilizing the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.
B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.
C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.
D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.
Correct Answer is D
Explanation
Rationale:
A. Take your temperature 1 hour after getting out of bed: Delaying temperature measurement can result in inaccurate readings due to physical activity or environmental changes, making it unreliable for detecting ovulation patterns.
B. Take your temperature every night before going to bed: Basal body temperature (BBT) must be taken in the morning, not at night, because the temperature needs to reflect complete rest, which occurs after several hours of sleep.
C. Take your temperature within 30 minutes after your first morning void: Voiding and moving around before taking your temperature can alter the basal reading, reducing the method’s accuracy for predicting fertile days.
D. Take your temperature immediately after waking and before getting out of bed: BBT should be taken at the same time each morning immediately upon waking and before any activity to ensure the most accurate and consistent readings for fertility tracking.
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