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    Ati RN pharmacology 2023 proctored exam

    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?

    Explanation & Rationale

    A. Vomiting 30 mL of fluid: Vomiting is a concern, but it is not the most immediate or life-threatening issue compared to respiratory depression, which is a critical risk with opioid use. The nurse should still address vomiting, but it is not the priority in this case. B. Blood pressure 90/60 mm Hg: Low blood pressure is a concern, but it is not as critical as respiratory depression when the client is receiving morphine. Hypotension can often be managed, and morphine’s effects on respiration can be life-threatening. C. Urinary output of 20 mL within 1 hr: While a low urinary output is concerning, it does not indicate an immediate emergency like respiratory depression. The nurse should continue monitoring urine output but focus on addressing respiratory issues first. D. Respirations deep at a rate of 10/min: Morphine, being a potent opioid, can depress the respiratory drive. A respiratory rate of 10/min, particularly with deep respirations, is an indication of respiratory depression, which is a life-threatening complication requiring immediate intervention. This is the priority finding as it can lead to hypoxemia and hypercapnia. .

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