A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief?

Question

Quizplus · Accepted Answer

Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% of normal ventilation), resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, especially during sleep. The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours. (Option A) This 22-year-old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior use. The nurse needs to assess the pain and any complications from narcotic use. However, this is not the first priority. (Option B) This 26-year-old has pneumonia and right side pain on deep inspiration, which indicate pleuritic pain (inflammation of the 2 layers of pleura). Pleuritic pain is an expected finding associated with pneumonia and is not the priority assessment. (Option C) Moderate to severe postoperative pain and lack of audible bowel sounds (due to general anesthesia, bowel manipulation, and opioid drugs) are expected findings 1 day after major abdominal surgery. This client is not the priority. Educational objective: Clients with obstructive sleep apnea (OSA) who are receiving sedatives or narcotics require frequent monitoring as these can exacerbate OSA symptoms. These clients are at increased risk for respiratory complications such as oversedation, respiratory depression, hypoxia, and hypercapnia.

A Nurse Is Assigned to Multiple Clients