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?

Urinary output 120 mL/4 hr

Pupil diameter 6 mm

Bowel movement 5 days ago

Blood pressure 80/40 mm Hg

Answer and Explanation

The Correct Answer is D

A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.

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Correct Answer is C

Explanation

A. An angiocatheter. This is used for peripheral IV access, not for accessing implanted venous ports. It is not designed to penetrate the septum of a port safely or effectively.
B. A 25-gauge needle. This needle is too small and not suitable for accessing a venous port, as it may not deliver adequate flow and can damage the port's septum.
C. A noncoring needle. Also known as a Huber needle, this is the correct choice for accessing an implanted port. It has a deflected tip that prevents coring (removing pieces of the port’s septum), preserving the integrity of the port and reducing the risk of damage or infection.
D. A butterfly needle. These are typically used for short-term venous access or blood draws and are not appropriate for accessing an implanted port. They lack the design necessary to protect the septum of the device.

A. Decrease the maintenance infusion rate of IV fluid. B. Have protamine sulfate available at the bedside. C. Reposition the client side-to-side each hour. D. Monitor the client for hypertension

Correct Answer is C

Explanation

A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.

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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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