A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?
Hypertension
Lacrimation
Tachycardia
Urinary retention
The Correct Answer is D
Choice A Reason:
Hypertension (high blood pressure) is not a common adverse effect of morphine. Opioid medications are more likely to cause hypotension (low blood pressure).
Choice B Reason:
Lacrimation (excessive tearing) is not a typical adverse effect of morphine. Opioids can cause dry mouth and decreased tear production.
Choice C Reason:
Tachycardia (rapid heart rate) is not a common adverse effect of morphine. Morphine and other opioids are more likely to cause bradycardia (slow heart rate) or a decrease in heart rate.
Choice D Reason:
Urinary retention is an adverse effect associated with opioid medications like morphine. Opioids can cause relaxation of smooth muscles, including those in the urinary bladder, which can lead to difficulty or inability to urinate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹.
The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹.
Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.
Correct Answer is C
Explanation
Choice A Reason:
A nurse discovers that a client's family member has administered a PCA dose: While this is a medication administration concern, it might not always require an incident report, but it should be addressed by the healthcare team to prevent future occurrences.
Choice B Reason:
A nurse observes a client vomiting after receiving an oral pain medication: This could be a medication reaction or a side effect, and it should be documented in the client's medical record, but it may not necessarily require a separate incident report.
Choice C Reason:
A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. Incident reports are typically used to document unexpected events or situations that deviate from the standard of care, and this includes situations where errors occur that could potentially harm the patient. In this case, the IV pump delivering twice the prescribed amount of fluid is a medication error that should be reported to document the occurrence and to ensure that corrective actions are taken to prevent similar incidents in the future.
Choice D Reason:
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: This might be a situation that requires clarification and discussion among the healthcare team, but it may not necessarily require an incident report unless there is concern about patient safety.
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