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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is B.
Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves. The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist. The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.
Correct Answer is B
Explanation
The correct answer is B. Notify the charge nurse about the situation. Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions.
The nurse should not ask the client to sign the consent form anyway (A), as this would violate the patient's right to autonomy and self-determination.
The nurse should not remind the client about the specifics of the procedure (C) or explain to the client that the procedure will help treat his diagnosis (D), as these are not within the nurse's scope of practice and may be considered as giving medical advice.
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