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. Hypertension is a serious manifestation of an interaction between phenelzine, a monoamine oxidase inhibitor (MAOI), and tyramine-rich foods like aged cheese. This interaction can lead to a hypertensive crisis, which is a medical emergency.
B. Diarrhea is not a typical manifestation of the interaction between phenelzine and tyramine-rich foods. The primary concern is hypertension.
C. Bradycardia is not associated with the interaction between phenelzine and tyramine-rich foods. The interaction typically causes an increase in blood pressure, not a decrease in heart rate.
D. Somnolence is not a common manifestation of this interaction. The primary concern is the risk of hypertensive crisis.
Correct Answer is D
Explanation
A. Monitor the client’s thyroid function levels is not relevant to the administration of metformin, as metformin does not affect thyroid function.
B. Collect the client’s uric acid level is not necessary in this context, as metformin does not typically impact uric acid levels.
C. Obtain the client’s HDL level is not relevant to the administration of metformin, as metformin does not directly affect HDL levels.
D. Check the client’s glucose level is the most appropriate action, as metformin is an antidiabetic medication that lowers blood glucose levels. Monitoring the client’s glucose level will help assess the impact of the incorrect medication administration and guide further treatment.
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