A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric tube. Which of the following equipment should the nurse gather prior to the procedure?

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.

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.