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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Expect to have a rapid pulse rate for the first few weeks: A newly implanted ICD does not cause a rapid heart rate. In fact, it monitors for dangerous rhythms and delivers a shock if one is detected. A rapid pulse could signal a complication and should be reported immediately.

B. Return in two weeks for a follow-up MRI: MRIs are generally contraindicated unless the ICD is MRI-compatible, which is not always the case. Strong magnetic fields can interfere with the device, so alternative imaging is typically used unless cleared by a cardiologist.

C. Resume tub baths and swimming after 24 hr: Clients should avoid submerging the incision site in water until it is fully healed, typically after several weeks. Early immersion increases the risk of infection at the surgical site.

D. Wear loose-fitting clothing: Loose clothing prevents irritation and pressure on the incision site during the healing process. It also helps reduce discomfort and lowers the risk of disturbing the ICD leads or dressing.

A. Ham sandwich with milk B. Shrimp salad and tomato soup with milk C. Bacon and cheese quiche with milk D. Scrambled eggs and toast with milk

Correct Answer is D

Explanation

Rationale:

A. Ham sandwich with milk: Ham is pork, which is strictly prohibited under kosher dietary laws. Additionally, meat and dairy cannot be consumed together in a kosher meal, making this choice doubly inappropriate for someone following kosher rules.

B. Shrimp salad and tomato soup with milk: Shellfish, including shrimp, are non-kosher because they lack fins and scales. Combining shrimp (non-kosher seafood) with dairy also violates kosher dietary principles, making this an unsuitable option.

C. Bacon and cheese quiche with milk: Bacon is pork and non-kosher, and mixing it with cheese violates the rule against combining meat and dairy. Even if the bacon were turkey-based, kosher observance would still require strict supervision and certification.

D. Scrambled eggs and toast with milk: Eggs, bread, and milk are all permissible under kosher law if prepared in accordance with kosher standards. This option avoids mixing meat and dairy and excludes non-kosher animals, making it suitable for a kosher diet.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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