Difficulty: Medium
Average Score: 64%
Simulated
A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion. Which of the following findings should the nurse report to the provider immediately?
Correct answer
B
Rationale
The correct answer is B: Respiratory rate 10/min. This finding should be reported immediately because it indicates respiratory depression, a serious side effect of morphine. A respiratory rate of 10/min is below normal range (12-20/min) and can lead to hypoxia and respiratory arrest. Prompt intervention is crucial to prevent further complications.
Other choices are incorrect because:
A: Constipation is a common side effect of morphine but does not require immediate reporting.
C: Facial flushing is a common side effect of morphine and does not indicate a medical emergency.
D: Blood pressure of 88/56 mm Hg is low, but not as critical as respiratory depression in this context.
Other choices are incorrect because:
A: Constipation is a common side effect of morphine but does not require immediate reporting.
C: Facial flushing is a common side effect of morphine and does not indicate a medical emergency.
D: Blood pressure of 88/56 mm Hg is low, but not as critical as respiratory depression in this context.