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?
Respirations deep at a rate of 10/min
Urinary output of 20 mL within 1 hr
Vomiting 30 mL of fluid
Blood pressure 90/60 mm Hg
The Correct Answer is A
A) Respirations deep at a rate of 10/min: This finding indicates respiratory depression, which is a significant concern with morphine administration. Respiratory depression can lead to hypoxia and respiratory arrest, posing a life-threatening situation for the client. Therefore, it is the priority finding that requires immediate intervention, such as reducing the dose of morphine, administering naloxone (an opioid antagonist), or providing respiratory support.
B) Urinary output of 20 mL within 1 hr: While decreased urinary output may indicate potential renal impairment or dehydration, it is not as immediately life-threatening as respiratory depression. However, it should still be monitored and addressed appropriately.
C) Vomiting 30 mL of fluid: Vomiting can be a side effect of morphine but may not require immediate intervention unless it leads to aspiration or dehydration. Nonetheless, it should be closely monitored for complications.
D) Blood pressure 90/60 mm Hg: Hypotension can occur as a side effect of morphine due to its vasodilatory effects. While low blood pressure should be addressed, it is not as immediately life-threatening as respiratory depression. Monitoring and appropriate interventions, such as fluid administration or adjusting the dose of morphine, can be implemented to manage hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Stroke volume: Stroke volume is the amount of blood ejected from the heart with each contraction, and it's an essential parameter in assessing cardiac function. However, when titrating a nitroprusside infusion, the primary goal is to manage blood pressure rather than directly targeting stroke volume. Nitroprusside is primarily used as a vasodilator to lower blood pressure in hypertensive emergencies. While changes in blood pressure may indirectly affect stroke volume, blood pressure itself is the primary parameter for titration.
B) Cardiac output: Cardiac output, which is the volume of blood pumped by the heart per minute, may be affected by nitroprusside due to its vasodilatory effects. However, like stroke volume, cardiac output is not typically the primary parameter for titrating a nitroprusside infusion. Blood pressure is a more direct indicator of the drug's effect on vascular tone and perfusion pressure.
C) Urine output: Monitoring urine output is crucial for assessing renal function and fluid status, but it is not the primary parameter used to titrate a nitroprusside infusion. While nitroprusside may affect renal blood flow and urine output indirectly, blood pressure remains the immediate indicator of the drug's hemodynamic effects.
D) Blood pressure: Nitroprusside is a potent vasodilator commonly used to lower blood pressure in hypertensive emergencies. Therefore, the primary assessment parameter for titrating a nitroprusside infusion is blood pressure. The nurse should monitor the client's blood pressure frequently and adjust the infusion rate accordingly to achieve the desired therapeutic effect while avoiding hypotension or excessive lowering of blood pressure.
Correct Answer is C
Explanation
A) Elevate the extremity: This action helps reduce swelling and minimizes the spread of infiltrated fluid into surrounding tissues by using gravity to assist in draining the excess fluid back into the bloodstream. Elevating the affected limb above the level of the heart promotes venous return and can help prevent further tissue damage.
B) Flush the IV catheter: Flushing the IV catheter could exacerbate infiltration by pushing more fluid into the surrounding tissue. It is not the appropriate action for managing infiltration and could worsen the client's condition.
C) Slow the infusion rate: Slowing the infusion rate is a reasonable action to reduce the flow of fluid into the tissues and minimize further infiltration. However, it may not be sufficient to manage existing infiltration effectively or prevent tissue damage.
D) Apply pressure to the IV site: Applying pressure to the IV site is not recommended for managing infiltration. It could cause further tissue damage and discomfort for the client and is not considered a standard practice in managing this complication.
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