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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Blurred vision is a known adverse effect of carbamazepine. Clients should be instructed to monitor for changes in vision and report any issues to their healthcare provider.
B. Tachypnea is not a common adverse effect of carbamazepine. It is more likely to be associated with respiratory conditions or other medications.
C. Insomnia is not typically associated with carbamazepine. In fact, carbamazepine can cause drowsiness and sedation.
D. Metallic taste is not a common adverse effect of carbamazepine. It is more commonly associated with other medications, such as metronidazole.
Correct Answer is ["325"]
Explanation
Step 1: Convert the client’s weight from pounds to kilograms. 143 lbs ÷ 2.2 = 65 kg (rounded to the nearest whole number)
Step 2: Calculate the dosage in mcg. 5 mcg × 65 kg = 325 mcg
The nurse should administer 325 mcg per day.
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