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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Arationale:
Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.
Choice Brationale:
You should not massage the site following the injection as this could cause bruising.
Choice Crationale:
With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.
Choice D rationale:
Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.
Correct Answer is A
Explanation
Choice A rationale:
“Inject the medication into the subcutaneous tissue of your abdomen.” This is correct because exenatide is a type of medication that needs to be injected subcutaneously for it to be absorbed into the body properly.
Choice B rationale:
“Discard excess medication after 60 days.” This statement is incorrect because exenatide pens are usually good for 30 days after the first use.
Choice C rationale:
“Take the medication at bedtime.” This is incorrect because exenatide should be taken within 60 minutes before the morning and evening meal.
Choice D rationale:
“Contact the provider if you experience unexplained muscle pain.” While this is generally good advice when starting any new medication, muscle pain is not a common side effect of exenatide.
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