Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
A. Assisting with a naloxone challenge test before therapy begins B. Discontinuing the drug immediately if signs of dependence appear C. Changing the administration route to P.O. if the client can tolerate fluids D. Obtaining baseline vital signs before administering the first dose
Y. Dawne, Content Blogger, Diploma in Journalism, Amsterdam, Netherlands
Answered Feb 07, 2019
The correct answer to this question is D.
Morphine Sulfate is an opioid anagelsic that is primarily metabolized by the liver. Nurses should monitor blood pressure prior to administration, and hold if systolic BP < 100 mm Hg or 30 mm Hg below baseline. Also, monitor the patient's respiratory rate prior to administration, and reassess pain after administration of morphine. The nurse should continue monitoring for respiratory depression and hypotension frequently up to 24 hours after administration of morphine. Place call light signal close to patient, and accompany patient, if needed, to get out of bed to minimize risk of falls.