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
Explanation
A. This statement reflects a misconception about menopause and sexual health, indicating a need for education on safe sex practices.
B. This statement indicates the client is taking steps to address discomfort during sexual activity, which is appropriate.
C. This statement reflects body image concerns commonly experienced by older adults and may warrant further exploration but does not necessarily indicate a need for immediate intervention.
D. This statement indicates a normal interest in sexual activity and does not necessarily indicate a need for intervention.
Correct Answer is B
Explanation
A. Maintaining a consistent sleep schedule is important for stress management; variability in sleep times can exacerbate stress.
B. Social support can help alleviate stress by providing a sense of belonging and sharing experiences.
C. Regular exercise is beneficial for stress management, but the frequency and duration may vary based on individual needs. However, 1 hour every week is little.
D. Delegating tasks can help reduce stress by distributing workload and responsibilities.
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