A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?
Respiratory rate 7/min
Distended bladder
Last bowel movement was 3 days ago
Reports pain of 8 on a scale from 0 to 10
The Correct Answer is A
A. A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B. While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C. Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D. Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Hypocalcemia can lead to paresthesia, including tingling sensations around the lips.
B. Abdominal distention is not typically associated with hypocalcemia.
C. Hypocalcemia can result in a positive Trousseau's sign, where carpal spasm is induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.
D. Chvostek's sign is typically positive in hypocalcemia, not negative.
E. Hypocalcemia can cause muscle cramps due to increased neuromuscular excitability.

Correct Answer is A
Explanation
A. This response is appropriate because it shows empathy, respect, and interest in the client's feelings and thoughts. It also invites the client to explore and clarify their meaning of purpose and how it relates to their retirement.
B. This response is dismissive of the client’s concern.
C. While hobbies can be fulfilling, this response does not address the client's feelings of purposelessness directly.
D. This response minimizes the client's feelings and does not offer constructive solutions to address their concerns.
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