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. Obtain arterial blood gases is not the immediate action required for hypoglycemia. It is more relevant for assessing respiratory and metabolic status.
B. Warm formula to room temperature is not related to managing hypoglycemia. It is a standard practice for comfort but does not address the low blood glucose levels.
C. Administer IV dextrose is the appropriate action to treat hypoglycemia. IV dextrose provides a rapid source of glucose to raise blood sugar levels and prevent complications associated with hypoglycemia.
D. Discontinue the infusion is not the correct action. The infusion may need to be adjusted, but the immediate priority is to correct the hypoglycemia with IV dextrose.

A. Notify the provider. B. Apply a warm, moist compress. C. Aspirate fluid remaining in the catheter. D. Remove the IV catheter.

Correct Answer is D

Explanation

A. Notify the provider. While notifying the provider is important, it is not the immediate next step after stopping the infusion. The priority is to prevent further damage by removing the IV catheter.
B. Apply a warm, moist compress. This action may be appropriate depending on the type of vesicant, but it is not the immediate next step. The priority is to remove the IV catheter to prevent further extravasation.
C. Aspirate fluid remaining in the catheter. This action can help to remove any remaining vesicant from the tissue, but it is not the immediate next step. The priority is to remove the IV catheter.
D. Remove the IV catheter. This is the correct next step after stopping the infusion. Removing the catheter helps to prevent further leakage of the vesicant into the surrounding tissue, minimizing the risk of tissue damage.

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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?

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Naxlex Comprehensive Predictor Exams

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