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Difficulty: EasyPharmacological and Parenteral Therapies

A young adult who underwent an appendectomy two hours ago reports incisional pain rated as 8 on a 0-to-10 pain scale. The medication administration record includes a prescription for intravenous morphine sulfate. The client is currently resting with eyes closed, arouses easily to verbal stimuli, and has a respiratory rate of 10 breaths per minute. Which action should the nurse take?

  1. Withhold the prescribed opioid dose and notify the healthcare provider.Answer
  2. B
    Administer the prescribed medication slowly over five minutes.
  3. C
    Elevate the head of the bed to a high-Fowler's position before injecting the medication.
  4. D
    Administer half of the prescribed dose to provide pain relief while minimizing respiratory risks.

Answer

Withhold the prescribed opioid dose and notify the healthcare provider.
The correct action is to withhold the medication because the client's respiratory rate is 10 breaths per minute, which is below the normal range (12-20 breaths per minute). Administering an opioid to a client with an already compromised respiratory status can precipitate respiratory arrest. The nurse must prioritize physiological safety over pain relief.

Step-by-Step Solution

1
Assess the client's vital signs and sedation level.
The respiratory rate is 10 breaths per minute, which is below the normal adult range of 12 to 20 breaths per minute.
Baseline assessment is required before administering any central nervous system depressant.
2
Analyze the clinical findings against the planned intervention.
Morphine sulfate causes respiratory depression, which would worsen the client's already compromised respiratory status.
Ensuring the ABCs (Airway, Breathing, Circulation) is always the highest priority.
3
Determine the safest nursing action.
The medication must be withheld and the provider notified.
Administering the medication could lead to life-threatening respiratory arrest.

Key Concept

Opioid administration requires careful assessment of respiratory rate; doses must be withheld if the rate falls below 12 breaths per minute.
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Topics

Pharmacological and Parenteral Therapies

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