A nurse is collecting data from an adolescent who is postoperative and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Respiratory rate 10/min.
Bladder distention.
BP 108/64 mm Hg.
Nausea and vomiting.
The Correct Answer is A
Choice A reason:
The nurse's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.
Choice B reason:
Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.
Choice C reason:
A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.
Choice D reason:
Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Ibuprofen - Ibuprofen belongs to the nonsteroidal anti-inflammatory drugs (NSAIDs) class, which includes aspirin. Since the client reports an allergy to aspirin, there is a risk of cross- reactivity, leading to a potential allergic reaction. Therefore, Ibuprofen should be avoided.
Choice B reason:
Acetaminophen - Acetaminophen is not an NSAID, and it works differently from aspirin. It is a safe option for the client in the postpartum period to manage pain without causing a cross- reaction with their aspirin allergy. Acetaminophen primarily acts on the central nervous system to reduce pain and fever, making it suitable for the client.
Choice C reason:
Naproxen - Naproxen is also an NSAID, and like Ibuprofen, it carries the risk of cross-reactivity in someone allergic to aspirin. Therefore, Naproxen should be avoided in this client.
Choice D reason:
Celecoxib - Celecoxib is a type of NSAID known as a selective cyclooxygenase-2 (COX-2) inhibitor. Although it is a bit more selective and generally considered to have a lower risk of causing cross-reactions, it is still an NSAID and not recommended for someone with a known aspirin allergy. Hence, Celecoxib should not be administered to the client in this scenario.
Correct Answer is C
Explanation
"I will reinforce the patch edges with clear tape if they don't lie flat.".
Choice A reason:
Placing a heat pack on the patch to improve adhesion is not recommended. Heat can potentially increase the absorption of the medication and lead to adverse effects. Applying additional heat to the patch can be dangerous and may cause an overdose or other complications.
Choice B reason:
Placing the patch on the back side of the child's arm is not the correct application site for a methylphenidate transdermal patch. The appropriate site for application is typically the hip or the top of the buttocks. The back of the arm may not provide proper absorption and can result in suboptimal medication delivery.
Choice C reason:
This statement indicates an understanding of the teaching. Reinforcing the patch edges with clear tape if they don't lie flat is a recommended step to ensure proper adhesion of the patch. If the edges of the patch lift or don't stick properly, using clear tape can help keep the patch securely in place, ensuring continuous and consistent drug delivery.
Choice D reason:
Leaving the patch in place for no more than 9 hours is incorrect. The duration of wear for a methylphenidate transdermal patch varies depending on the specific brand and formulation. Typically, these patches are designed for 9 to 12 hours of wear, and leaving them on for a shorter duration may result in inadequate symptom control.
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