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    Hesi RN exit proctored examQuestion 61
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    Hesi RN exit proctored exam

    Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse monitors the client's dropdownafter administering the morphine. The nurse should include dropdownto reduce complications of the client's injury.

    Explanation & Rationale

    Rationale: Respirations: After administering morphine, it is crucial to monitor the client's respirations because opioids can cause respiratory depression, which may be more pronounced in elderly patients or those who are in pain and immobile. Deep breathing techniques: The nurse should encourage deep breathing techniques. This helps improve lung expansion and reduces the risk of respiratory complications such as pneumonia and atelectasis, especially in a client with decreased mobility due to pain and injury. Rationale for Incorrect Options: Heart rate: While heart rate monitoring is important, it is not the primary concern immediately after morphine administration. The client's respiratory status takes precedence, especially considering the risk of opioid-induced respiratory depression. Blood pressure: While blood pressure monitoring is essential, morphine administration primarily affects the respiratory system, not the circulatory system. The nurse should prioritize respiratory monitoring over blood pressure unless the patient exhibits signs of hypotension. Range of motion exercises: Range of motion exercises are important for mobility and rehabilitation, but they are not a priority immediately following the trauma and morphine administration. The client should be assessed and stabilized before beginning exercises. Joint protection techniques: Joint protection techniques are beneficial in long-term rehabilitation, but in the acute phase, the priority is to manage the fracture, pain, and prevent further complications.

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