Hi everyone, I have a question on a NCLEX practice question that I just do not understand why the answer is what it is. Here's the question...
A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis and nausea. The first action by the nurse should be
1. Order an EKG
2. Administer morphine sulphate
3. Start an IV
4. Measure vital signs
According to the NCLEX review the answer is 2.
We can assume that an EKG was done in the ER and that an IV was started. And I agree that pain should be addressed right away, however, from all my teaching at school, Morphine (or any other opioid) should never be given without assessing the respiratory rate (and that it's good to have a BP, but that respiratory rate was a MUST have). If I gave morphine in clinical without assessing the RR, I'd get written up.
Does anyone know why the answer would be 2. I'm concerned that when I go to take the NCLEX, I'll have problems with the disparity between what I was taught and what they want. Help!
Thanks for your opinions on this!
Mar 13, '05
Aha, but Morphine is given for MORE than the control of the pain in an MI. Morphine has another benefit--it actually improves the action of the heart by decreasing preload. Its vasodilator effect can also cause hypotension, an effect can also be a benefit in an AMI.
Last edit by UM Review RN on Mar 13, '05
Mar 13, '05
Pain also = tissue damage, you want to stop that immediately. Like Angie O said, opening up the vasculature (vasodilation) with morphine decreases the workload on the heart thereby decreasing oxygen requirements and comsumption of the heart. Heart doesn't work as hard; oxygen is used more efficiently.
Here's where you use your critical thinking - If the patient's in pain and talking to you, you can pretty much count on an adequate respiratory rate.
Be sure to take the entire situation into account. Not just step-wise things.
Last edit by begalli on Mar 13, '05