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. Slow change in dilation and effacement: Even slow cervical changes are indicative of true labor. False labor does not cause any progressive cervical dilation or effacement, making this an inconsistent finding for false labor.
B. Contraction intensity increased by ambulation: In true labor, contractions typically intensify with activity such as walking. In contrast, false labor contractions often diminish or resolve with changes in position or ambulation.
C. Presence of bloody show: Bloody show results from cervical dilation and the disruption of cervical capillaries. It is a hallmark of true labor and would not be expected during false labor.
D. Intermittent, painless contractions: False labor is characterized by irregular, non-progressive, and typically painless contractions, often referred to as Braxton Hicks contractions. These are normal in late pregnancy but do not indicate true labor.
Correct Answer is C
Explanation
Rationale:
A. Encourage the child to take naps during the day: While rest is important during flares, excessive daytime napping can contribute to stiffness and reduced physical function. Regular activity is encouraged to maintain joint mobility and overall well-being.
B. Apply splints to the child's extremities during the day: Splints may be used during sleep or periods of rest to reduce deformities, but wearing them during the day can interfere with play, physical therapy, and functional use of joints, which are important in school-age children.
C. Have the child take a tub bath each morning: Warm baths help relieve joint stiffness and pain, especially after nighttime immobility. Morning baths can promote flexibility, ease discomfort, and prepare the child for physical activity during the day.
D. Keep the child on bedrest as long as pain persists: Prolonged bedrest may worsen joint stiffness and muscle atrophy. Controlled physical activity is beneficial and helps prevent complications related to immobility. Pain management should support continued movement.
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