The physician has ordered an injection of morphine for a client with post-operative pain. Before administering the medication, it is essential that the nurse assess the client's?

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

Morphine, a potent opioid analgesic, directly suppresses the respiratory center in the brainstem, leading to a decreased respiratory rate and depth.
Respiratory depression is the most serious and life-threatening adverse effect of morphine, making the assessment of respiratory status the highest priority before administration.
Standard nursing practice requires withholding morphine and notifying the physician if the client's respiratory rate is below a critical threshold, typically 12 breaths per minute, to prevent severe respiratory compromise.

Option A: While morphine can cause bradycardia (slow heart rate), this effect is less common and less immediately life-threatening than respiratory depression.
Option C: Morphine has no direct or significant effect on body temperature. Assessing temperature is not a priority related to morphine administration.
Option D: Morphine can cause hypotension (low blood pressure), particularly orthostatic hypotension. However, this is a secondary concern compared to the immediate risk of respiratory arrest.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing assessment before administering opioid analgesics (morphine) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Always prioritize the ABCs (Airway, Breathing, Circulation) in patient assessment. For opioids, 'Breathing' is the most critical and immediate concern.
Nurses must have the opioid antagonist, naloxone (Narcan), readily available whenever administering opioids to reverse severe respiratory depression in an emergency.
What if? The client was an older adult with chronic kidney disease. The nurse's assessment would be even more critical, as impaired renal function can lead to the accumulation of morphine and its metabolites, increasing the risk and duration of respiratory depression.

How to Approach the Question

First, identify the drug mentioned in the question: Morphine.
Recall the drug class: Morphine is an opioid analgesic.
Think about the most serious, life-threatening side effect of this drug class. For opioids, this is respiratory depression.
Connect the most serious side effect to the required nursing assessment. To monitor for respiratory depression, the nurse must assess the client's respirations.
Evaluate the options based on this priority. While heart rate and blood pressure can be affected, they are not the primary life-threatening risk. Temperature is unrelated.
Select the option that addresses the highest-priority safety check.

Concept Tested & Keywords

Concept Tested: Priority nursing assessment before administering opioid analgesics (morphine).
Stem keywords: morphine, post-operative pain, administering medication, assess
Lead-in keywords: essential
Clinical cues: post-operative pain (indicates need for strong analgesic)
Clinical cues: morphine (a potent opioid with known side effects)

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E6 Pharmacology Nursing Lilley 11e Part 1 pp. 177-179, 196-198

E6 Nursing Fundamentals Taylor p. 241-243

Practise the full DHS Staff Nurse - 2018 (Shift-2nd)

Attempt every question from this paper in a timed mock, then review the full solution for each one.