Page 2079 - Saunders Comprehensive Review For NCLEX-RN

and incentive spirometry to prevent atelectasis and
pneumonia.
10. Monitor level of consciousness.
11. Initiate safety precautions such as a night light and
supervised ambulation.
12. Monitor intake and output.
13. Assess for urinary retention.
14. Instruct the client to take oral doses with milk or a
snack to reduce gastric irritation.
15. Instruct the client to avoid alcohol.
16. Instruct the client to avoid activities that require
alertness.
17. Assess bowel function for constipation, abdominal
distention, and decreased peristalsis.
18. Evaluate the effectiveness of medication.
19. Have an opioid antagonist, oxygen, and resuscitation
equipment available.
D. Morphine
1. Side and adverse effects

a. Respiratory depression

b. Orthostatic hypotension
c. Urinary retention
d. Nausea and vomiting
e. Constipation
f. Sedation, confusion, and hallucinations
g. Cough suppression
h. Reduction in pupillary size
i. Miosis

2. Interventions

a. Have naloxone available for overdose.
b. Assess vital signs and level of
consciousness.
c. Compare rate and depth of respirations
to baseline.
d. Withhold the medication if the

respiratory rate is less than 12 breaths
per minute; respirations of less than 10
breaths per minute can indicate
respiratory distress.
e. Monitor urinary output, which should
be at least 30 mL/hr.
f. Monitor bowel sounds for decreased
peristalsis, because constipation can
occur.

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