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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?

A.

Pupil diameter 6 mm

B.

Blood pressure 80/40 mm Hg

C.

Urinary output 120 mL/4 hr

D.

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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Related Questions

Correct Answer is C

Explanation

Rationale:

A. Temperature 37.7° C (99.9° F): This temperature is only slightly elevated and not strongly indicative of infection. Endometritis typically presents with a fever above 38°C (100.4°F), reflecting a more pronounced inflammatory response.

B. Polyuria: Increased urine output is not a characteristic sign of endometritis. It may be seen with conditions such as diabetes mellitus or post-diuresis but is unrelated to uterine infection.

C. Malodorous lochia: Foul-smelling lochia is a key clinical sign of endometritis, indicating infection of the uterine lining. It often accompanies uterine tenderness, fever, and possibly abdominal pain.

D. Heart rate 56/min: Bradycardia is not typical in endometritis. Instead, clients may present with tachycardia as part of the systemic inflammatory response to infection. A low heart rate would be unexpected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

  • Hypercapnia: This is a hallmark of malignant hyperthermia (MH), resulting from uncontrolled calcium release in muscle cells leading to increased metabolism and CO2 production. It is not typical of latex allergy or hypovolemic shock. Neither condition causes increased carbon dioxide retention from muscle metabolism.
  • Tachycardia: Elevated heart rate is common in MH due to hypermetabolic state, in latex allergy as part of anaphylaxis response, and in hypovolemic shock as a compensatory mechanism for decreased circulating volume.
  • Wheezing: Wheezing reflects bronchospasm, a common feature of latex allergy/anaphylaxis, but is not a symptom of MH or hypovolemic shock.
  • Urticaria (hives): Urticaria is a typical allergic skin reaction seen in latex allergy but is absent in MH and hypovolemic shock.
  • Muscle rigidity: Muscle rigidity, particularly jaw muscle rigidity (masseter spasm), is a classic sign of MH due to abnormal muscle metabolism. This finding is not associated with latex allergy or hypovolemic shock.

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