Patient Data
The nurse needs to determine the priority assessment before administering morphine.
Select from Word Choices to complete the sentence.
Before administering morphine, the most important assessment to perform is to check the client's ______________
Temperature
Heart rate
Respiratory rate
Blood pressure
The Correct Answer is C
A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.
B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.
C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.
D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A. St. John's wort: This herbal supplement is not used to manage opioid side effects and may interact with other medications, including opioids, making it inappropriate for this purpose.
B. Sildenafil: Sildenafil is used to treat erectile dysfunction and has no role in managing morphine side effects. It is unrelated to pain management or opioid-related adverse effects.
C. Ondansetron: Ondansetron is an antiemetic commonly prescribed to prevent or treat nausea and vomiting, which are frequent side effects of morphine administration.
D. Naloxone: Naloxone is an opioid antagonist used to reverse severe opioid-induced respiratory depression. It is essential for emergency management of potentially life-threatening side effects of morphine.
E. Meperidine: Meperidine is an opioid analgesic and is not used to treat side effects of morphine. Using another opioid would not address morphine-induced complications and may increase risk of adverse effects.
F. Docusate sodium: Opioid-induced constipation is common with morphine. Docusate sodium is a stool softener used prophylactically to prevent or treat constipation associated with opioid therapy.
Correct Answer is D
Explanation
A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.
B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.
C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.
D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.
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