A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?

Question

Quizplus · Accepted Answer

Opioids, including morphine sulfate, dilate peripheral blood vessels and can cause hypotension. The side effect is not as noticeable when the client is lying down; however, once the client attempts to stand, it can cause orthostatic hypotension. It is more common in clients who have some underlying volume depletion (eg, opioid-induced nausea/vomiting). Due to the safety risk, clients must be taught to rise slowly from a sitting to a standing position. The nurse should first assist the client to sit if the client feels lightheaded in a standing position. Safety is the client's priority. If orthostasis is evident, fluid bolus may be needed and should be communicated to the health care provider. (Options A and D) Assessing the client's orthostatic vital signs and recommending bed rest until the lightheadedness resolves are important but not first-priority actions. (Option C) Walking with the client is not recommended when the client is symptomatic on standing. Educational objective: Client safety is the priority action in any situation. The nurse should assist the client to a safe position prior to proceeding with other interventions.

A Client Is Taking Morphine Sulfate for Acute Pain