A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.

Which of the following actions should the nurse take?

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.

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.

The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.

Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.

Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.

The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.

Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.

The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.

Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.