A nurse is caring for a client who received a dose of IV morphine for pain. Which of the following vital signs indicates the client is having an adverse reaction to the medication?
Blood pressure 140/86 mm Hg
Temperature 37.50 C (99.50 F)
Heart rate 65/min
Respiratory rate 10/min
The Correct Answer is D
Respiratory rate of 10/min indicates respiratory depression which a potential adverse effect of morphine. Opioids suppress the central respiratory centers leading to respiratory depression. Use of two opioids increases their levels in blood raising the risk of respiratory depression even higher which is fatal.
A.- Elevated blood pressure is not directly related to morphine use . Could be an indication of pain
B.-Normal temperature
C.-Normal heart rate
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
Nifedipine is a calcium channel blocker is used in the management of hypertension. It leads to vasodilation of blood vessels lowering blood pressure. Nifedipine is a calcium channel blocker commonly used to treat hypertension and angina. Therefore, the nurse should assess the client's blood pressure prior to administering nifedipine to ensure that it is within the therapeutic range and not too low, as nifedipine can cause hypotension (as a side effect.
B,C, D- Nifedipine has no effect on respiratory rate, temperature and oxygen saturation
Correct Answer is D
Explanation
Fluid deficit causes the loss of the plasma component of blood. The levels of blood cells remain constant despite the loss of plasma resulting in hemoconcentration. Hemoconcentration is observed as an elevated hematocrit level on a full blood count test.
A,B,C- features of fluid overload
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