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?

Urinary output of 20 mL within 1 hr

Blood pressure 90/60 mm Hg

Vomiting 30 mL of fluid

Respirations deep at a rate of 10/min

Answer and Explanation

The Correct Answer is D

A) Urinary output of 20 mL within 1 hr:
While low urinary output is a concern and could indicate issues such as dehydration or renal impairment, it is not the most immediate threat to the client's life when compared to respiratory depression.

B) Blood pressure 90/60 mm Hg:
A blood pressure of 90/60 mm Hg is hypotensive and should be monitored, but it is not as immediately life-threatening as respiratory depression in the context of morphine administration.

C) Vomiting 30 mL of fluid:
Vomiting is a common side effect of morphine but does not present as immediate a danger as respiratory depression. It can be managed with antiemetics and supportive care.

D) Respirations deep at a rate of 10/min:
Correct. Respiratory depression is a serious and potentially life-threatening side effect of morphine. A respiratory rate of 10 breaths per minute, even if the respirations are deep, indicates that the client's breathing is significantly slower than normal. This requires immediate attention because if untreated, it can lead to hypoxia, respiratory arrest, and death. The nurse should prioritize assessing and addressing this finding, potentially by reducing the morphine dose or administering naloxone if necessary.

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Correct Answer is C

Explanation

Answer: C. "Ensure that the air bubble remains in the syringe."

A. "Inject the medication into the lateral thigh."
This is incorrect for enoxaparin administration. Enoxaparin, a low-molecular-weight heparin, should be injected into the subcutaneous tissue of the abdomen, preferably in the fatty tissue around the navel or the outer aspects of the abdomen, to ensure proper absorption.

B. "Release the skin fold before injecting the medication."
This is incorrect. The skin fold should be held throughout the injection to ensure that the medication is delivered into the subcutaneous tissue and not the muscle. Releasing the skin fold too early may risk deeper muscle injection.

C. "Ensure that the air bubble remains in the syringe."
This is the correct practice for enoxaparin injections. The air bubble in the prefilled syringe is intended to ensure that the entire dose of medication is delivered and to prevent leakage of the medication from the injection site. It also helps to clear the needle of medication after injection.

D. "Rub the site after injecting the medication."
This is incorrect. Rubbing the site after administering enoxaparin can increase the risk of bruising and tissue irritation, as enoxaparin is an anticoagulant that can increase bleeding tendencies. It is recommended to avoid rubbing the site after injection.

A. Melena B. Abdominal cramping C. Fever D. Hair loss

Correct Answer is A

Explanation

Answer: A. Melena

Rationale:

A. Melena:
Melena, which is the passage of dark, tarry stools, indicates upper gastrointestinal bleeding. In a client taking warfarin, this finding is particularly concerning as it suggests a significant risk for hemorrhage. The priority is to report this to the healthcare provider immediately, as it may require urgent intervention, including possibly adjusting the warfarin dosage or initiating treatment for bleeding.

B. Abdominal cramping:
While abdominal cramping can be a side effect of various conditions and may indicate gastrointestinal distress, it is not as critical as melena in the context of a client on warfarin. Further evaluation may be warranted, but it does not pose an immediate risk like melena.

C. Fever:
A fever could indicate an infection or an inflammatory process, but in the context of a client on warfarin, it is not a direct indicator of a serious adverse effect related to anticoagulation. Monitoring is necessary, but it does not require immediate reporting compared to signs of bleeding.

D. Hair loss:
Hair loss is a potential side effect of many medications, including warfarin, but it is generally not life-threatening or indicative of a severe complication. While it may warrant discussion with the provider for management, it does not require urgent attention like melena does.

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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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Correct Answer is A

Explanation

Rationale:

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