A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.
Which of the following findings should the nurse report to the provider immediately?

Respiratory rate 10/min.

Facial flushing.

Constipation.

Blood pressure 88/56 mm Hg.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.

Choice B rationale:

Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.

Choice C rationale:

Constipation is a common side effect of morphine and can be managed with laxatives and diet.

Choice D rationale:

Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.

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Correct Answer is C

Explanation

Choice A rationale:

Atenolol is a beta-blocker used to treat high blood pressure and heart-related conditions. It’s not used in the treatment of alcohol use disorder.

Choice B rationale:

Lorazepam is a benzodiazepine used to treat anxiety disorders. It can be used in the acute management of alcohol withdrawal, but it doesn’t assist in maintaining abstinence.

Choice C rationale:

Disulfiram is a medication used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol (drinking alcohol) If alcohol is consumed when a patient has received disulfiram treatment, they suffer from a disulfiram-alcohol reaction, which can include symptoms like flushing, nausea, vomiting, and headaches. This aversive effect aids in discouraging the consumption of alcohol.

Choice D rationale:

Carbamazepine is an anticonvulsant and mood stabilizer medication used primarily in the treatment of epilepsy and bipolar disorder, not for alcohol use disorder.

A. "Take the medication with a sip of water.” B. "Take one tablet before a strenuous activity.” C. "Take up to four tablets in 15 minutes.” D. "Chew each tablet completely before swallowing.”

Correct Answer is B

Explanation

Choice A rationale:

Sublingual nitroglycerin should be taken without water. The tablet should be placed under the tongue and allowed to dissolve.

Choice B rationale:

It is recommended to take sublingual nitroglycerin before activities that might cause angina.

Choice C rationale:

The maximum recommended dosage is three tablets within 15 minutes, not four.

Choice D rationale:

Sublingual nitroglycerin should not be chewed. It should be allowed to dissolve under the tongue.

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A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

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A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.
Which of the following findings should the nurse report to the provider immediately?