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
A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
D) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
Correct Answer is D
Explanation
Choice A Reason:
"I will no longer be able to eat nuts." While it's essential to be cautious about certain foods after a colostomy, avoiding nuts altogether may not be necessary. The client should discuss dietary restrictions with their healthcare provider or a registered dietitian.
Choice B Reason:
"I will empty the pouch every 2 to 3 hours." The frequency of pouch emptying can vary depending on the client's individual needs and the ostomy type. There's no fixed schedule for emptying the pouch, so this statement is not necessarily accurate.
Choice C Reason:
"I should expect my stool to be formed." The consistency of stool from a colostomy can vary depending on the location of the stoma and the type of colostomy. It may be formed or semi-formed, but it can also be more liquid or loose, depending on the circumstances. The client should
Choice D Reason:
"I will notify my doctor if the stoma starts to look purple." This statement reflects the client's awareness of the importance of monitoring the stoma's color and seeking medical attention if it appears discolored or compromised. A purple or dark-colored stoma can indicate inadequate blood supply, which is a concern that should be addressed promptly.
discuss stool consistency with their healthcare provider.
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