Question

The nurse is preparing to administer morphine sulfate to a client recently returned from surgery. Before giving the medication, what is the priority nursing assessment? A. Checking the client's respirations B. Obtaining the client's temperature C. Checking the client's blood pressure D. Counting the client's pulse rate

Short answer

Answer: The priority nursing assessment is checking the client's respirations.

Step-by-step solution

Option A: Checking the client's respirations

Morphine sulfate is an opioid analgesic that can cause respiratory depression as a side effect. It is essential to check the client's respirations before administering the medication to ensure the patient isn't already experiencing any respiratory complications. If the client's respiration is too low, the nurse might withhold the medication or administer a lower dose.

Option B: Obtaining the client's temperature

While it is important to monitor the client's temperature, especially after surgery, it is not directly related to the administration of morphine sulfate. Therefore, obtaining the client's temperature is not the priority assessment in this case.

Option C: Checking the client's blood pressure

Morphine sulfate can also cause a decrease in blood pressure. It is important to check the client's blood pressure before administering the medication. However, considering the potential respiratory depression side effect, this is not the priority assessment compared to the client's respiration.

Option D: Counting the client's pulse rate

Monitoring the client's pulse rate is important, but it is not the priority assessment in this case. The primary concern associated with the administration of morphine sulfate is respiratory depression.

Conclusion

The priority nursing assessment before administering morphine sulfate to a client recently returned from surgery is checking the client's respirations (Option A). This is crucial due to the potential side effect of respiratory depression associated with morphine sulfate use.

Key concepts

Nursing Assessments

Before administering any medication, a thorough nursing assessment is vital. For nurses, this involves evaluating the patient's current condition and any factors that might affect their safety when receiving medication. The goal is to ensure that the treatment will be both effective and safe for the patient.

Key considerations in nursing assessments include:

• Respiratory rate and quality, especially important when administering drugs like opioids.
• Blood pressure and heart rate to identify any cardiovascular concerns.
• Patient's level of consciousness to ensure they can respond appropriately.
• Overall pain levels to see if the medication will provide needed relief.

Conducting these assessments helps in identifying any life-threatening conditions that need immediate attention, such as respiratory distress that might be exacerbated by administering certain medications.

Morphine Sulfate

Morphine sulfate is a potent opioid used to relieve severe pain, often post-operatively. It works by attaching to opioid receptors in the brain, diminishing the sensation of pain.

Here are some important points about morphine sulfate:

• It is highly effective in managing pain but carries significant side effects.
• Respiratory depression is one of its most serious side effects due to its impact on the central nervous system.
• Morphine can also cause drowsiness, constipation, and nausea.

Understanding how morphine sulfate affects the body is crucial for safe administration, as is knowledge of proper dosing to avoid adverse reactions.

Respiratory Depression

Respiratory depression is a dangerous side effect of morphine sulfate. It occurs when there is a decrease in the ability to breathe effectively, which can lead to inadequate oxygen supply to the body.

Signs of respiratory depression include:

• Shallow or slowed breathing.
• Pale or bluish skin (cyanosis).
• Confusion or lethargy.
• Reduced response to external stimuli.

Monitoring is essential, particularly after opioid administration. If respiratory depression happens, the morphine dose may need adjustment, or alternative pain management strategies should be considered.

Post-Operative Care

Post-operative care is the care given to patients immediately following surgery. Its importance cannot be overstated as it can significantly impact recovery.

Important aspects of post-operative care include:

• Pain management, often using medications like morphine for comfort.
• Monitoring of vital signs to detect any complications early.
• Promoting mobility to prevent complications such as blood clots and improve recovery speed.
• Wound care to prevent infection.

Effective post-operative care ensures the patient's safety and promotes healing, making the role of a nurse in this period crucial.