can't find the prioritization answer

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2 would be the answer because pain is NEVER a life threatening condition. If you had pain of 8/10 and a respiratory rate of 12, the respiratory rate would be the most crucial. The #1 thing that you look for with ANY narcotic pain relief if respiratory depression

NursingBro

258 Posts

2 is my answer and 4 is nclex answer.

NursingBro

258 Posts

Oh heck, let's call Aunt Marlene (Hurst)! LOL:)

I emailed hurst the question lol

birdlover12

23 Posts

@nursingbro..lol

Specializes in Home health.

I would definitely put answer 2. I have seen a few nclex questions and their rationales do not always make sense. Either the wording of the question is wrong or the answer they r choosing is incorrect. Throughout the whole nursing school they've been teaching us that the only time pain is the priority is when abcs r ok

PrinceofSiamRN

47 Posts

When I was reviewing, I chose number 2 as my answer and I am super confident at that moment with smile and swag haha. But to my big surprise,it turned out that the NCLEX answer was number 4. (whhhaaaaattt???).yeah it is haha, And as far as I can remember, eliminating 1 and 3 first which leave you number 2 and 4 which are the most concern. But comparing the two choices,the rationale that I've read stated that 4 should be the answer since the goal is to eliminate MI chest pain. Presence of pain even in the lowest rate can still compromise oxygen perfusion since this pain indicates that there's still Infarction going on. And I have read in La Charity sthat there are only two kinds of pain that can/might overpower are famous A-B-C sequence.

First, the M.I. pain

Second,the pain from compartment syndrome that needs emergency fasciotomy

Hope these helped you even a little (lol), I'm just sharing what I read and my ideas,but you'll still have the last say or just research it on your own when you have time so that you will be sure cause you might get confused of different answers shared by members including me.hehe. It is really good to find it on your own so that when exam comes,you will have your OWN FIRM ANSWER to attack the question =)

Godbless and Mahalo from Hawaii =)

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Q:

you have give Morphine sulfate 4mg IV to a client who has an acute MI. when you evaluate the client's response 5 mins after giving the medication, which of these indicates a need for immediate further actions?

A:

1. the blood pressure decreases from 114/65 to 106/58 mm Hg.

2. the respiratory rate drop from 18 to 12 breaths/min.

3. the cardiac monitor indicates sinus rhythm at a rate of 96 beats/min.

4. the client still has chest pain at level of 1(on a scale of 0 to 10)

anyone who can help me find the right answer? :)and why ?

Well......

1. The B/P drop 5 min after administering Morphine....is not a significant drop.

2. The resp rate drop when this is five min after IV Morphine, while it bears watching, the resp rate is still within normal limits.

3. The cardiac monitor tells me that the patient has a normal is not slightly rapid heart rate after MS04 administration indicating some distress.

4. The patient continues to have pain indication that further interventions will be necessary.

Number 4.

Helenz

5 Posts

thank you for all you help, the right answer is #4.

answer key from book: Goal in pain management for the client with an acute MI is to completely eliminate the pain.Even pain rated at a level of 1 out of 10,should be treated with additional morphine(possibly lower dose).the other date indicate a need for ongoing assessment for the possible adverse effects of hypertension respiratory depression, and tachycardia but do not require further action at this time.

psu_213, BSN, RN

3,878 Posts

Specializes in Emergency, Telemetry, Transplant.

In terms of action, it would have to be 4 as the other instances "only" require monitoring (for now) not "action."

However, I disagree with the "goal" the all pain needs to be completely. A person can live with 1/10 pain...the cannot live with significant heart muscle death. The real action that every needs to work for is reperfusion therapy, and ten does of morphine is not going to accomplish that goal.

gatoraims RN

219 Posts

In terms of action, it would have to be 4 as the other instances "only" require monitoring (for now) not "action."

However, I disagree with the "goal" the all pain needs to be completely. A person can live with 1/10 pain...the cannot live with significant heart muscle death. The real action that every needs to work for is reperfusion therapy, and ten does of morphine is not going to accomplish that goal.

I agree, I can see the rational behind answer 4 but would never pick that answer on a test. I think a pt breathing is more important than taking away all pain. We could easily kill this person by trying to make their pain 0. The pt's tissue may have already been compromised and I would think the goal is to perfuse tissue, control pain and anxiety (decreases work load of heart and a level 1 of pain would do this), and prevent further muscle damage.

Ahh...I meant to say it is #4. :confused:

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