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 D
Explanation
Choice A Reason:
Explaining the procedure's purpose is incorrect. While explaining the procedure's purpose is essential, it should not be done as a sole response if the client has expressed a lack of understanding. The client's concerns and questions need to be addressed first.
Choice B Reason:
Reminding the client about the specifics of the procedure is incorrect. This choice assumes that the client is aware of the specifics but has forgotten them. If the client has already stated that they don't understand why the procedure is necessary, simply reminding them of the details may not address their concerns adequately.
Choice C is Reason:
Asking the client to sign the consent form anyway is incorrect. This option is not appropriate because it would violate the principle of informed consent. Informed consent requires that the client fully understands the procedure, its purpose, potential risks, and alternatives before signing the form. If the client doesn't understand, signing the form would not be informed consent.
Choice D Reason:
Notifying the charge nurse about the situation is correct. When a client expresses a lack of understanding or confusion about a medical procedure, it is essential to ensure that the client fully comprehends the procedure, its purpose, potential risks, and alternatives. The nurse should not proceed with obtaining informed consent if the client does not understand. Instead, the charge nurse or another healthcare provider should be notified to address the client's concerns and provide further clarification. It's crucial to prioritize the client's right to make an informed decision regarding their healthcare.
Correct Answer is A
Explanation
Choice A Reason:
"This medication prevents your baby from developing bleeding problems." This is the correct statement. Phytonadione is given to newborns to prevent neonatal vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including intracranial hemorrhage.
Choice B Reason:
"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.
Choice C Reason:
"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.
Choice D Reason:
"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.
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