A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

Vomiting 30 mL of fluid

Blood pressure 90/60 mm Hg

Respirations deep at a rate of 10/min

Urinary output of 20 mL within 1 hr

Answer and Explanation

The Correct Answer is C

A. Vomiting 30 mL of fluid. This finding is not the priority because while vomiting can be a side effect of morphine, it is not immediately life-threatening.
B. Blood pressure 90/60 mm Hg. This finding is concerning but not the priority. Morphine can cause hypotension, but the primary concern with morphine administration is respiratory depression.
C. Respirations deep at a rate of 10/min. This finding is the priority because morphine can cause respiratory depression, which can be life-threatening. Monitoring and addressing respiratory status is critical when administering opioids.
D. Urinary output of 20 mL within 1 hr. This finding is concerning but not the priority. Low urinary output can indicate dehydration or renal issues, but respiratory depression is the most immediate concern with morphine administration.

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Correct Answer is C

Explanation

A. Bradypnea is not a common adverse effect of amiodarone. Respiratory effects are less common compared to cardiac effects.
B. Fever can occur with amiodarone but is not the most common or critical adverse effect.
C. Bradycardia is a well-known adverse effect of amiodarone. Amiodarone can slow the heart rate significantly, leading to bradycardia, which requires monitoring and potential intervention.
D. Hypertension is not typically associated with amiodarone. Amiodarone is more likely to cause hypotension rather than hypertension.

A. Elevated hematocrit level B. Weight gain C. Shortness of breath D. Distended neck veins

Correct Answer is A

Explanation

A. Elevated hematocrit level can indicate hemoconcentration due to fluid volume deficit. When there is a decrease in plasma volume, the concentration of red blood cells increases, leading to a higher hematocrit level.
B. Weight gain is typically associated with fluid retention, not fluid volume deficit. In heart failure, weight gain can indicate worsening fluid overload.
C. Shortness of breath is a common symptom of fluid overload in heart failure, not fluid volume deficit. It occurs due to pulmonary congestion and edema.
D. Distended neck veins are a sign of increased central venous pressure, often seen in fluid overload rather than fluid volume deficit.

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A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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