A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?
Prolonged QT interval
Fluid retention
Bradypnea
Hyperactive deep tendon reflexes
The Correct Answer is C
Rationale:
A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.
B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.
C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.
D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Pale and a 24-hr fluid deficit of 30 mL: Mild pallor and a small fluid deficit are not uncommon in early stages of illness and may not require immediate intervention. However, more serious signs of dehydration would take priority for reporting.
B. Temperature 38° C (100.4° F) and pulse rate 124/min: These are within expected limits for an infant with mild infection or fever. While they should be monitored, they are not urgent indicators of severe complications from gastroenteritis.
C. Decreased appetite and irritability: These are common symptoms in infants with viral illnesses, including gastroenteritis. Although they affect comfort and feeding, they are not necessarily indicators of serious fluid or electrolyte imbalance.
D. Sunken fontanels and dry mucous membranes: These are clinical signs of moderate to severe dehydration, which is a serious complication of gastroenteritis in infants. These findings must be reported promptly for urgent intervention to prevent further deterioration.
Correct Answer is D
Explanation
Rationale:
A. Misoprostol: Misoprostol is a prostaglandin used to stimulate uterine contractions and control postpartum hemorrhage. It is generally safe for clients with hypertension, as it does not cause significant vasoconstriction or elevate blood pressure.
B. Oxytocin: Oxytocin is commonly used to manage postpartum hemorrhage by inducing uterine contractions. It does not have hypertensive effects and is safe for use in clients with a history of high blood pressure.
C. Terbutaline: Terbutaline is a beta-agonist used for tocolysis, not for treating postpartum hemorrhage. Although it may cause tachycardia and hypotension, it is not a uterotonic and is not relevant in this context.
D. Methylergonovine: Methylergonovine is contraindicated in clients with hypertension because it causes intense vasoconstriction, which can significantly elevate blood pressure and increase the risk of stroke or cardiac events in hypertensive clients.
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