Patient Data Exhibits What actions should the nurse take to ensure safety during morphine administration? Select all that apply.

Choice A reason: Taking an initial respiratory rate is a necessary action to ensure safety during morphine administration, as morphine can cause respiratory depression, which is a potentially life-threatening side effect. The nurse should monitor the client's respiratory rate and oxygen saturation regularly and report any signs of respiratory distress or hypoxia to the physician. Therefore, choice A is correct. Choice B reason: Performing a 12-lead electrocardiogram is not a necessary action to ensure safety during morphine administration, as morphine does not have a significant effect on the cardiac rhythm or conduction. The nurse should monitor the client's heart rate and blood pressure regularly and report any signs of bradycardia, hypotension, or chest pain to the physician. Therefore, choice B is incorrect. Choice C reason: Suctioning the client to clear the airway is not a necessary action to ensure safety during morphine administration, as morphine does not cause excessive secretions or bronchospasm that would obstruct the airway. The nurse should assess the client's level of consciousness and gag reflex regularly and report any signs of sedation, confusion, or aspiration to the physician. Therefore, choice C is incorrect. Choice D reason: Having a manual resuscitation bag at the bedside is a necessary action to ensure safety during morphine administration, as morphine can cause respiratory depression that may require emergency intervention. The nurse should be prepared to administer oxygen and naloxone (an opioid antagonist) as ordered and perform rescue breathing or cardiopulmonary resuscitation if needed. Therefore, choice D is correct. Choice E reason: Asking the client about other medications she takes is a necessary action to ensure safety during morphine administration, as morphine can interact with other drugs that may enhance or reduce its effects or cause adverse reactions. The nurse should review the client's medication history and current medications and report any potential drug interactions or contraindications to the physician. Therefore, choice E is correct. Choice F reason: Restraining the client with soft restraints is not a necessary action to ensure safety during morphine administration, as morphine does not cause agitation or delirium that would warrant physical restraint. The nurse should provide a safe and comfortable environment for the client and report any signs of anxiety, hallucinations, or psychosis to the physician. Therefore, choice F is incorrect.