Difficulty: Medium
Average Score: 69%
Simulated
Passage / Scenario
History and PhysicalThe client is a 42-year-old female who had a right above-the-knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1.
Nurses' Notes
1400: Started continuous morphine in the left antecubital vein peripheral intravenous line. No redness, edema, or bleeding noted at the site. Vital signs are heart rate 77 bpm, blood pressure 118/74 mmHg, respiratory rate 16 breaths/min.
Orders
ÔÇó Admit to the surgical floor
ÔÇó Clear liquid diet, advance as tolerated
ÔÇó Continuous cardiorespiratory monitoring
ÔÇó Morphine 1 mg/hr intravenously
ÔÇó Alert surgeon to signs of bleeding or infection in the surgical site
1500:
ÔÇó Docusate sodium 240 mg orally every am
ÔÇó Naloxone 2 mg intravenously as needed for respiratory depression
ÔÇó Ibuprofen 600 mg orally every 6 hours
The charge nurse places a fall precautions sign on the client's door. What side effects of morphine could contribute to this client's fall risk? Select all that apply.
Correct answer
B,C,D,E,F,G
Rationale
Nausea, orthostatic hypotension, sedation, euphoria, itching, and urinary retention can cause dizziness, weakness, or distraction, increasing fall risk. Seizures are rare with therapeutic morphine doses.