can't find the prioritization answer

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  1. This is a discussion on can't find the prioritization answer in NCLEX Discussion Forum, part of Nursing Student ... Q: you have give Morphine sulfate 4mg IV to a client who has an acute MI. when you evaluate the...

    by Nov 17, '12
    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 ?
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    by Helenz Nov 17, '12 1:26 pm
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  3. 47 Comments so far...

  4. Nov 17, '12 by
    4. bcoz goal for morphine sulfate is to eliminate pain. other answer just show assessments of its side effects. Ive just encountered this same question during my review.
    Last edit by killerbee on Nov 17, '12
    Helenz likes this.
  5. Nov 17, '12 by
    In this question, ask yourself, what is the goal and point of giving the medication to a patient with a certain diagnosis?

    In this case, what is the goal of giving the medication - morphine sulfate - to the patient with an acute MI? Why give morphine sulfate as opposed to another drug? What makes giving morphine sulfate to a patient with an acute MI so imperative? What are the possible side-effects you should really watch out for?

    Once you think of that, you can eliminate a lot of the choices and see which one is the best response answer.
    Helenz likes this.
  6. Nov 17, '12 by
    Quote from Helenz
    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 ?
    But the question is looking for further assessment after administration of morphine and number 4 choice is a normal response after administration of morphine.
    I guess my answer would be (1)blood pressure drops from 114/65-106/58
    Number 2 choice is a normal side effect morphine which is a respiratory depressant.
    And I'm not sure about number 3 which the patient became tachycardic.
  7. Nov 17, '12 by
    2. This is a significant drop in respiratory rate. Respiratory depression is a side effect of morphine. While a respiratory rate of 12 might be normal for an adult, but the fact that it's such a significant change in only 5 minutes, it could be an indication that the patient's respiratory status is becoming compromised.

    1. Is not a problem. This is a slight, normal drop in blood pressure likely related to decreased pain.

    3. Is not a problem. Sinus rhythm is a normal rhythm and 96 is an appropriate heart rate for this patient.

    4. Is not a problem. It may not be possible to eliminate pain in a patient having an MI. Not to mention, it's only been 5 minutes since you administered the medication. It may not have taken full effect.
    SummitRN, lemmyg, Esme12, and 3 others like this.
  8. Nov 17, '12 by
    ans 4 there should be no pain.
  9. Nov 17, '12 by
    oh sorry i think its 2
    respiratory rate has fallen
  10. Nov 17, '12 by
    I think 2 is the answer.
  11. Nov 17, '12 by
    If the pt. is still having pain it's your priority to get it to 0.
  12. Nov 17, '12 by
    Good luck