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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Fever: Fever is a nonspecific but common symptom found in all three conditions—epiglottitis, RSV, and streptococcal pharyngitis. However, it is more severe and abrupt in epiglottitis and low to moderate in RSV and strep throat. In this case, the toddler has had a persistent fever over 38°C, consistent with both RSV and strep.
Exudate on pharynx: Pharyngeal exudate is a hallmark sign of acute streptococcal pharyngitis, resulting from the inflammatory response to GABHS. It is not typical in RSV or epiglottitis, where erythema and swelling may occur but without purulent exudate.
Wheezing upon auscultation: Wheezing is a classic sign of RSV, a lower respiratory viral infection leading to bronchiolitis and airway obstruction. It is not a feature of epiglottitis or strep throat, which involve the upper airway and oropharynx, respectively.
Drooling: Drooling is strongly associated with epiglottitis, due to inflammation and swelling of the epiglottis which makes it painful and difficult to swallow. It is not typical in RSV or strep pharyngitis unless there is severe oral involvement or dehydration.
Hypoxia: Hypoxia may occur in both epiglottitis and RSV due to airway obstruction or inflammation compromising oxygenation. In epiglottitis, it results from upper airway narrowing; in RSV, from lower airway inflammation and mucus plugging. It is not common in uncomplicated streptococcal pharyngitis.
Tachypnea: Tachypnea is a sign of respiratory distress and is often present in both epiglottitis and RSV, as the body attempts to compensate for impaired gas exchange. It is not a primary feature of strep pharyngitis unless accompanied by systemic infection or high fever.

A. Ketorolac B. Aspirin C. Acetaminophen D. Obuprofen

Correct Answer is C

Explanation

A. Ketorolac. This is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Aspirin. Aspirin is also an NSAID and can irritate the gastric lining, increasing the risk of ulceration and bleeding. It is contraindicated in clients with peptic ulcers.
C. Acetaminophen. Acetaminophen is the safest option for clients with peptic ulcer disease because it does not affect the gastric mucosa. It provides effective relief for mild to moderate pain, including headaches.
D. Ibuprofen. Like ketorolac and aspirin, ibuprofen is an NSAID and is not recommended for clients with peptic ulcers due to the increased risk of gastrointestinal irritation and bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

Correct Answer is C

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

A nurse is caring for a client who is postoperative following a right hip arthroplasty. For each assessment finding, click to specify if the finding is consistent with Malignant hyperthermia, Latex allergy, or Hypovolemic shock. Each finding may support more than 1 disease process.

A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan of care?

A nurse in an emergency department is planning care for a client who has abdominal trauma from a motor-vehicle crash. Which of the following provider prescriptions should the nurse implement first?