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 A

Explanation

Rationale:

A. Discuss the client's food preferences with the hospital's dietitian: Collaborating with the dietitian allows the meal plan to be adjusted based on the client’s cultural, religious, or taste preferences while still meeting dietary requirements. This promotes adherence to the prescribed diet and supports patient-centered care.

B. Allow the client’s family to bring food from home for the client: While family support is valuable, food brought from home may not comply with the ADA diet. This can compromise glucose control unless the food is reviewed and approved by a dietitian.

C. Offer the client’s meals on a different schedule: Changing the meal schedule may not address the client’s refusal to eat if the issue is related to food content rather than timing. Consistency in meal timing is also important in managing blood glucose levels.

D. Request the provider change the client’s prescribed diet: Altering the diet order without first exploring and addressing the client’s preferences or challenges may lead to poor glucose control. The nurse should advocate for personalized modifications rather than a blanket diet change.

A. Trochanter roll B. Footboard C. Sheepskin heel pad D. Abduction pillow

Correct Answer is B

Explanation

Rationale:

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobile. It does not support the feet or ankles and therefore does not prevent plantar flexion contractures.

B. Footboard: A footboard helps maintain the foot in a dorsiflexed, neutral position by providing firm support against the soles. This prevents foot drop, a common plantar flexion contracture in clients with limited mobility.

C. Sheepskin heel pad: Sheepskin heel pads protect the heels from pressure ulcers by reducing friction and shear but do not maintain ankle alignment or prevent plantar flexion of the feet.

D. Abduction pillow: An abduction pillow is placed between the legs to maintain hip alignment after procedures like hip replacement. It offers no support to the feet and does not prevent plantar flexion.

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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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