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
Explanation
Choice A Reason:
Select the central tip of a finger is incorrect. The nurse should select a puncture site on the side of the finger, slightly off-center from the central tip, as it tends to be less painful. The side of the finger has an adequate blood supply and can provide an accurate blood sample without causing excessive discomfort.
Choice B Reason:
Wearing sterile gloves is incorrect. Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. However, clean hands and proper hand hygiene are essential. The nurse should perform hand hygiene before the procedure.
Choice C Reason:
Keeping the finger in a dependent position is correct. Keeping the finger in a dependent position (hanging down) can promote blood flow and make it easier to obtain a blood sample. This is a recommended technique to facilitate the puncture and collection of blood.
Choice D Reason:
Milking may hemolyze specimen and introduce excess tissue fluid.
Correct Answer is D
Explanation
Choice A Reason:
Clear rhinorrhea (runny nose without any other symptoms) is not a contraindication for receiving the varicella vaccine. Contraindications typically involve more serious medical conditions or situations where the vaccine could be harmful.
Choice B Reason:
Medications for a cardiac anomaly. Taking medications for a cardiac anomaly is not a contraindication for the varicella vaccine. In fact, some children with cardiac anomalies may be at higher risk for complications from chickenpox and may benefit from vaccination.
Choice C Reason:
Two diarrhea stools in the last day. Having a couple of episodes of diarrhea in the last day is not a contraindication for the varicella vaccine. Contraindications usually involve more severe or systemic conditions that can affect the safety and effectiveness of the vaccine.
Choice D Reason:
Chemotherapy treatments is correct. A contraindication for receiving a varicella (chickenpox) immunization is undergoing chemotherapy or other immunosuppressive therapies. Children who are immunocompromised should not receive live vaccines like the varicella vaccine because of the risk of developing the disease due to their weakened immune system.
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