A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching? Select all that apply.

Choice A reason:

Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.

Choice B reason:

A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.

Choice C reason:

A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.

Choice A reason: Temperature 38.2°C (100°F)

A temperature of 38.2°C (100°F) is slightly elevated and could indicate an infection or other inflammatory response. However, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms. Monitoring and further assessment are necessary, but it is not the highest priority.

Choice B reason: The client reports weakness of the lower extremities

Weakness of the lower extremities can be a side effect of epidural analgesia. While it is concerning and requires monitoring, it is not as immediately critical as severe hypotension. The nurse should assess the extent of the weakness and ensure the client’s safety, but it is not the top priority.

Choice C reason: The client reports some itching

Itching is a common side effect of opioid analgesia and, while uncomfortable, it is not dangerous. It can be managed with antihistamines or other medications. This symptom does not require urgent intervention and is not the highest priority.

Choice D reason: Blood pressure 80/56 mm Hg

A blood pressure of 80/56 mm Hg indicates significant hypotension, which can be life-threatening for both the mother and the fetus. Hypotension can lead to decreased perfusion to vital organs and the placenta, potentially causing fetal distress. Immediate intervention is required to stabilize the client’s blood pressure and ensure adequate blood flow to the fetus. This makes it the highest priority for the nurse to address.