can't find the prioritization answer

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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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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.

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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.

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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.

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Specializes in PICU, Sedation/Radiology, PACU.

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.

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ans 4 there should be no pain.

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oh sorry i think its 2

respiratory rate has fallen

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I think 2 is the answer.

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If the pt. is still having pain it's your priority to get it to 0.

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Good luck :)

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What a/b the #1, BP? I know it's only a small dip, but hypotension = decreased perfusion, which is a SE of morphine. This is undesirable during an acute MI.

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i took this q and its correct answer is 4 becuse goal is to eliminate pain comletely...if patient show 1 on sacle it mean he /she still have blood deprived to mycordaial muscle ....purpose is ti pain scale should be 0:up:

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