A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago.

Which of the following findings is the nurse’s priority?

Euphoria

Bradypnea

Constipation

Answer and Explanation

The Correct Answer is B

The correct answer is choice B, bradypnea. Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.

Choice A, euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.

Euphoria is not a priority finding and does not indicate a serious complication of morphine.

Choice C, constipation, is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.

Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.

Choice D, sedation, is wrong because sedation is another common side effect of morphine that affects the central nervous system.

Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.

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Correct Answer is D

Explanation

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice Creason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

A. I can lift objects that are less than 10 pounds B. I can resume activities, such as sewing C. I can go jogging after 2 weeks D. I should bend at the waist when putting on my shoes

Correct Answer is A

Explanation

The correct answer is A. I can lift objects that are less than 10 pounds.

Here's a breakdown of why the other options are incorrect:

B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.

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A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago.

Which of the following findings is the nurse’s priority?