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A nurse is assessing a client's response to receiving morphine for postoperative pain management. Which of the following findings is the nurse's priority?

A.

Hypotension

B.

Bradycardia

C.

Bradypnea

D.

Pruritus

Answer and Explanation

The Correct Answer is C

A. Hypotension: While hypotension can be a concern with opioid use, it is less immediately life-threatening compared to respiratory depression, which is the most dangerous side effect of morphine. Monitoring BP is important, but the priority is airway and breathing.

B. Bradycardia: Bradycardia is a possible side effect of morphine, but it does not usually present an immediate risk to the client's life unless it is severe. Respiratory depression poses a greater risk to the client’s oxygenation status.

C. Bradypnea: Bradypnea (slow breathing) is the most critical concern when a client is receiving morphine. Opioids like morphine can cause respiratory depression, which can be life-threatening. This should be the nurse's priority to assess and address immediately.

D. Pruritus: Pruritus (itching) is a common side effect of morphine, but it is not life-threatening. While it can be uncomfortable, it does not require immediate intervention compared to respiratory depression.


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Related Questions

Correct Answer is A

Explanation

A. "If you have a cat, wear gloves when cleaning the litter box.": Cat litter can contain Toxoplasma or Bartonella, which can increase the risk of infection and sepsis in immunocompromised clients. Wearing gloves reduces exposure to potential pathogens.
B. "Floss your teeth after every meal.": Flossing after every meal may be too frequent and could cause irritation or gum injury, which increases the risk of infection. Good oral hygiene is important, but over-flossing should be avoided, especially for clients at risk of sepsis.
C. "Store your toothbrush in a glass filled with distilled water.": Storing a toothbrush in distilled water does not provide additional protection against infection. The toothbrush should simply be kept clean and dry to avoid bacterial growth.
D. "Do not consume cold drinks that have been left out for more than 1 hour.": This advice is generally good for food safety but is not specifically related to sepsis risk. The main focus should be on preventing infections that could lead to sepsis, rather than on drink temperature.

Correct Answer is ["30"]

Explanation

Calculation:

  • Determine the concentration of the available lidocaine solution in milligrams per milliliter (mg/mL).

Available concentration = Total medication (mg) / Total volume (mL)

= 400 mg / 100 mL

= 4 mg/mL.

  • Convert the desired dose from milligrams per minute (mg/min) to milligrams per hour (mg/hr).

1 hr = 60 min

Desired dose in mg/hr = 2 mg/min × 60 min/hr

= 120 mg/hr.

  • Calculate the IV pump rate in milliliters per hour (mL/hr).

IV pump rate (mL/hr) = Desired dose (mg/hr) / Available concentration (mg/mL)

= 120 mg/hr / 4 mg/mL

= 30 mL/hr.

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