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. Blood pressure is the primary assessment used to titrate a nitroprusside infusion. Nitroprusside is a potent vasodilator used to rapidly lower blood pressure in hypertensive emergencies. Continuous monitoring of blood pressure is essential to ensure the medication is titrated correctly and to avoid hypotension.
B. Stroke volume is not the primary assessment for titrating nitroprusside. While stroke volume is an important measure of cardiac function, blood pressure is the key parameter for adjusting nitroprusside dosage.
C. Urine output is an important indicator of renal function and overall fluid balance, but it is not the primary assessment for titrating nitroprusside. Blood pressure monitoring is more directly related to the effects of nitroprusside.
D. Cardiac output is an important measure of overall heart function, but it is not the primary assessment for titrating nitroprusside. Blood pressure is the most critical parameter to monitor when adjusting the infusion rate of nitroprusside.
Correct Answer is D
Explanation
A. Administer the medication while wearing protective footwear is not a standard precaution for administering hazardous IV medications. Protective footwear is generally used to prevent physical injuries rather than chemical exposure.
B. Wear an N95 respiratory mask when administering the medication is necessary for airborne precautions but not typically required for administering hazardous IV medications unless there is a risk of aerosolization.
C. Administer the medication in a negative pressure room is used for airborne infection isolation but is not a standard requirement for administering hazardous IV medications.
D. Wear gloves when handling the medication is essential to protect the nurse from exposure to hazardous drugs. Gloves provide a barrier to prevent skin contact with the medication, reducing the risk of absorption and contamination.
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