can't find the prioritization answer - page 3

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... Read More

  1. Visit  NursingBro} profile page
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    Quote from nrs209
    Oh heck, let's call Aunt Marlene (Hurst)! LOL
    I emailed hurst the question lol
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  3. Visit  birdlover12} profile page
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    @nursingbro..lol
  4. Visit  HH_RN13} profile page
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    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
  5. Visit  PrinceofSiamRN} profile page
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    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 =)
    Helenz likes this.
  6. Visit  mariebailey} profile page
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  7. Visit  Esme12} profile page
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    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 ?
    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 likes this.
  8. Visit  Helenz} profile page
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    thank you for all you help, the right answer is #4.

    answer key from book: [FONT=verdana, arial, helvetica, sans-serif]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.
  9. Visit  psu_213} profile page
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    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.
    Last edit by psu_213 on Nov 18, '12
  10. Visit  gatoraims RN} profile page
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    Quote from psu_213
    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.
  11. Visit  mariebailey} profile page
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    Quote from mariebailey
    Ahh...I meant to say it is #4.
  12. Visit  madel0119} profile page
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    id choose #2 think about ABC respiratory rate is dropping 18 down to 12 per min its alarming
  13. Visit  2bFNP4ME2015} profile page
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    The question asked for "immediate" action for response. I would select #2 because my immediate response to 12 breaths/minute is to encourage deep breathing. If the patient "still" has a pain rate of 1. I don't think you would immediately give more Morphine to make his pain rate 0. The goal is to promote perfusion to the heart and decrease further ischemia ( which is causing the chest pain).
  14. Visit  psu_213} profile page
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    Quote from OrNurrse03
    The question asked for "immediate" action for response. I would select #2 because my immediate response to 12 breaths/minute is to encourage deep breathing. If the patient "still" has a pain rate of 1. I don't think you would immediately give more Morphine to make his pain rate 0. The goal is to promote perfusion to the heart and decrease further ischemia ( which is causing the chest pain).
    I like your though of the action of encouraging deep breathing. On the other hand, option 4 does not say that your action has to be give more morphine. The question is only asking which piece of assessment data requires action. The action could be to give NTG.


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