Question

in which situation does the nurse consider withholding scheduled morphine until further assessment is completed?

1. client reports acute pain from deep partial thickness burns affecting the lower extremities.
2. clients respirations are 28 and regular and bp is 110/76 mmhg.
3. clients level of consciousness fluctuates from drowsy to lethargic.
4. client exhibits restlessness, anxiety, and cold, clammy skin.

Explanation:

Morphine is an opioid analgesic with sedative and respiratory - depressant effects. A client whose level of consciousness fluctuates from drowsy to lethargic may be experiencing excessive sedation, which is a sign of opioid overdose or excessive effect. In such a case, the nurse should withhold the scheduled morphine and conduct further assessment to determine if the morphine is causing this altered level of consciousness or if there are other underlying issues.

• Option 1: A client with deep partial - thickness burns and acute pain would likely require morphine for pain management, so withholding is not indicated.
• Option 2: A respiratory rate of 28 (which is above the normal range of 12 - 20 but not severely depressed) and a blood pressure of 110/76 mmHg do not indicate a need to withhold morphine.
• Option 4: Restlessness, anxiety, and cold, clammy skin may be signs of other conditions like shock, but not a direct indication to withhold morphine.

Answer:

1. Client's level of consciousness fluctuates from drowsy to lethargic.