Difficulty: Medium
Average Score: 76%
Simulated
A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?
Correct answer
A
Rationale
The correct answer is A: Respiratory rate 7/min. This is the priority because a respiratory rate of 7/min is significantly low and could indicate respiratory depression, a serious side effect of morphine. Inadequate ventilation can lead to hypoxia and respiratory arrest. Monitoring and addressing respiratory status is crucial for patient safety.
Incorrect Choices:
B: Distended bladder - While a distended bladder should be addressed, it is not as immediate a concern as respiratory depression.
C: Last bowel movement was 3 days ago - Constipation is a common side effect of morphine but does not pose an immediate threat to the client's health.
D: Reports pain of 8 on a scale from 0 to 10 - Pain management is important but not as urgent as assessing for respiratory depression.
Incorrect Choices:
B: Distended bladder - While a distended bladder should be addressed, it is not as immediate a concern as respiratory depression.
C: Last bowel movement was 3 days ago - Constipation is a common side effect of morphine but does not pose an immediate threat to the client's health.
D: Reports pain of 8 on a scale from 0 to 10 - Pain management is important but not as urgent as assessing for respiratory depression.