The nurse is caring for a client receiving morphine sulfate 2–4 mg IV every 4 hours as needed for pain. The client's family calls the nurses' station to request pain medication for the client. When the nurse arrives in the room, the client is lying in the bed. The nurse obtains the following vital signs: BP 120/80, P 80, and R 8. What is the nurse's first action?
1. Call the physician after giving the pain medication
2. Call the physician
3. Find out when the client had the last dose of medication
4. Withhold the medication
4
Rationale 1: The medication should be withheld for respirations less than 12 breaths per minute.
Rationale 2: The first priority is to withhold the medication.
Rationale 3: The first priority is to withhold the medication.
Rationale 4: The nurse should withhold medication for any difficulty in breathing or respirations below 12 breaths per minute.
Global Rationale: The nurse should withhold medication for any difficulty in breathing or respirations below 12 breaths per minute. It is not necessary to call the physician after giving the pain medication. Although the nurse will call the physician because of the respiratory rate, this is not the priority. Although the nurse will review the time of the last dose of medication, this is not the priority.
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