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 ["50"]
Explanation
Step 1: Determine the total volume to be infused. 100 mL
Step 2: Determine the time in minutes over which the infusion will be administered. 30 minutes
Step 3: Calculate the flow rate in mL/min. 100 mL ÷ 30 minutes = 3.33 mL/min
Step 4: Calculate the flow rate in gtt/min using the drop factor. 3.33 mL/min × 15 gtt/mL = 49.95 gtt/min
Step 5: Round to the nearest whole number. 50 gtt/min
The nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is C
Explanation
A. A client receives their meal tray 20 minutes late is an inconvenience but does not typically require an incident report unless it results in significant harm or a pattern of delays that affect patient care.
B. A client experiences a seizure is a medical emergency that requires immediate attention and documentation in the client’s medical record, but it does not necessarily require an incident report unless it was caused by an error or unexpected event.
C. A client receives their insulin 1 hour before scheduled is a medication error that requires an incident report. Administering insulin at the wrong time can lead to significant changes in blood glucose levels and potential harm to the client, making it necessary to document the incident and investigate the cause.
D. A client vomits after receiving an oral medication should be documented in the client’s medical record, but it does not typically require an incident report unless it was caused by an error or unexpected event.
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