A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?
The client's blood pressure has been reduced.
The client exhibits diaphoresis
The client is not grimacing
The client has an elevated heart rate
The Correct Answer is C
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
Correct Answer is D
Explanation
Performing oral care every 2 hours is an important nursing intervention for a client receiving mechanical ventilation via an endotracheal tube. This helps to reduce the risk of ventilator-associated pneumonia.
a) Monitoring the client's vital signs is important, but it should be done more frequently than every 8 hours.
b) Repositioning the endotracheal tube is not necessary unless there is a specific indication.
c) Placing the client in a supine position is not recommended as it increases the risk of aspiration.
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