Difficulty: Medium
Average Score: 78%
Simulated
A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?
Correct answer
D
Rationale
The correct answer is D: Respirations deep at a rate of 10/min. This is the priority finding because it indicates respiratory depression, a serious side effect of morphine. Low respiratory rate and deep breathing can lead to hypoxia and respiratory arrest. Monitoring respiratory status is crucial when administering opioids.
A: Urinary output of 20 mL within 1 hr - While decreased urinary output may indicate decreased renal perfusion, respiratory depression is a more immediate concern.
B: Blood pressure 90/60 mm Hg - Hypotension can be a side effect of morphine, but respiratory depression takes precedence.
C: Vomiting 30 mL of fluid - Although vomiting can be a side effect of morphine, it is not as immediately life-threatening as respiratory depression.
A: Urinary output of 20 mL within 1 hr - While decreased urinary output may indicate decreased renal perfusion, respiratory depression is a more immediate concern.
B: Blood pressure 90/60 mm Hg - Hypotension can be a side effect of morphine, but respiratory depression takes precedence.
C: Vomiting 30 mL of fluid - Although vomiting can be a side effect of morphine, it is not as immediately life-threatening as respiratory depression.