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 C
Explanation
Rationale:
A. "Avoid high-fiber foods while taking this medication." High-fiber foods are encouraged when taking opioids like fentanyl due to the common side effect of constipation. Dietary fiber supports bowel function and should not be avoided.
B. "Apply the patch to your forearm." The patch should be applied to a flat, non-irritated area with minimal hair, such as the chest, back, or upper arm. The forearm is not the preferred site due to its mobility and smaller surface area.
C. "Avoid hot tubs while wearing the patch." Heat increases the absorption rate of transdermal fentanyl, potentially leading to overdose. Clients should avoid hot tubs, heating pads, or prolonged exposure to direct sunlight while wearing the patch.
D. "Remove the patch for 8 hours every day to reduce the risk of tolerance." Fentanyl patches are designed to provide continuous pain control and should not be removed intermittently. Removing the patch disrupts pain management and does not prevent tolerance, which is managed by medical adjustment if necessary.
Correct Answer is C,D,A,B
Explanation
Rationale:
A. Close all nearby windows and doors: Containment helps prevent the spread of smoke and flames. Closing doors and windows minimizes oxygen supply to the fire and keeps it from moving into other areas.
B. Use the unit's fire extinguisher to attempt to put out the fire: The final step is to extinguish the fire, but only if it is safe to do so. The nurse should not attempt this before ensuring safety, alerting others, and containing the fire.
C. Transport the client to another area of the nursing unit: The first priority in a fire situation is rescue, removing anyone in immediate danger, especially vulnerable clients who cannot evacuate themselves.
D. Activate the facility's fire alarm system: Once the client is safe, the next step is to alarm the system to alert others in the facility and begin emergency response protocols.
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