The client is prescribed morphine sulfate (MS Contin) for chronic back pain resulting from inoperable disk degeneration. What nursing actions are indicated?

Question

Standard Text: Select all that apply.
1. Use the prn order of docusate (Dulcolax) routinely every night.
2. Ask the dietary department to add bran cereal to the client's breakfast trays.
3. Ask the health care provider to write an order for an indwelling urinary catheter.
4. Review the trending of the client's hemoglobin and hematocrit levels.
5. Check the medical record for a prn order for an antiemetic.

Answer 1

Correct Answer: 1,2,4,5
Rationale 1: One of the adverse effects of morphine therapy is constipation. The nurse should be proactive by giving the docusate every night.
Rationale 2: Intake of additional fiber, as long as sufficient fluid is taken, is useful in preventing the constipation that is common with the use of morphine.
Rationale 3: While morphine may promote urinary retention, other methods of controlling this adverse effect should be used initially.
Rationale 4: Morphine should not be administered to those who are hypovolemic due to the risk of hypotension.
Rationale 5: Nausea and vomiting are adverse effects of the use of morphine. Until the client becomes tolerant of this effect, an antiemetic may be necessary.
Global Rationale: One of the adverse effects of morphine therapy is constipation. The nurse should be proactive by giving the docusate every night. Intake of additional fiber, as long as sufficient fluid is taken, is useful in preventing the constipation that is common with the use of morphine. Morphine should not be administered to those who are hypovolemic due to the risk of hypotension. Nausea and vomiting are adverse effects of the use of morphine. Until the client becomes tolerant of this effect, an antiemetic may be necessary. While morphine may promote urinary retention, other methods of controlling this adverse effect should be used initially.