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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A Positive Chvostek’s sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice B rationale:
Pitting pedal edema occurs when excess fluid builds up in the body, causing swelling. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice C rationale:
Decreased deep-tendon reflexes or hyporeflexia happens when your skeletal muscles have a decreased or absent reflex response. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice D rationale:
Decreased blood glucose level or hypoglycemia occurs when your blood sugar (glucose) level falls too low. Glyburide is an oral diabetes medicine that helps control blood sugar levels. Anxiety and profuse sweating are symptoms of low blood sugar.
Correct Answer is C
Explanation
Choice A rationale:
Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.
Choice B rationale:
While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.
Choice C rationale:
Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.
Choice D rationale:
Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.
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