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    Hesi RN Exit proctored examQuestion 127
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    Hesi RN Exit proctored exam

    Patient Data Exhibits The nurse addresses the client's pain and plans interventions to reduce further complications. 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 dropdown after administering the morphine. The nurse should includedropdown to reduce complications of the client's injury.

    Explanation & Rationale

    Rationale for correct choices: • Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression. • Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention. Rationale for incorrect choices: • Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety. • Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications. • Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises. • Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.

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