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?

Tachycardia

Lacrimation

Hypertension

Urinary retention

Answer and Explanation

The Correct Answer is D

The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

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Correct Answer is B

Explanation

The correct answer is choice B. Nontender, protruding abdomen.

Choice A rationale:

Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.

Choice B rationale:

A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.

Choice C rationale:

By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.

Choice D rationale:

Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.

A. Instruct the client to exhale while inserting the rectal tube. B. Insert the tip of the rectal tube 15 cm (6 in). C. Administer the enema using cool tap water. D. Administer a second enema if the first has poor results.

Correct Answer is A

Explanation

The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are

incorrect because they can cause injury or discomfort to the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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