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 ["B","C","E"]
Explanation
A. Comparing the medication administration record with the medication container should occur before documentation to ensure accuracy.
B. This step ensures that the nurse is administering the correct medication to the client.
C. Comparing the medication against the administration record while removing it from the container helps prevent errors.
D. While important, this step does not directly involve comparing the medication container with the administration record.
E. Verifying the medication at the bedside ensures the right medication is given to the right patient at the right time.
Correct Answer is D,E,C,B,A
Explanation
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
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