Question

A client receives intrathecal morphine to control severe postoperative pain. Which action will the nurse include as part of the client's initial 24-hour postoperative care plan?

1 Monitoring of respiratory rate hourly
2 Assessing the client for tachycardia
3 Administering naloxone every 3 to 4 hours
4 Observing the client for signs of central nervous system (CNS) excitement

Answer 1

The nurse should include monitoring of the client's respiratory rate hourly in the initial 24-hour postoperative care plan.

Step-by-step explanation:

As part of the client's initial 24-hour postoperative care plan after receiving intrathecal morphine to control severe postoperative pain, the nurse should include monitoring of respiratory rate hourly.

This is important because morphine, as an opiate, can cause respiratory depression. Monitoring the client's respiratory rate helps ensure that their breathing is not compromised. If the respiratory rate decreases significantly, it may indicate a potential complication that needs immediate attention.

Assessing the client for tachycardia and signs of central nervous system (CNS) excitement are not directly related to the administration of intrathecal morphine. Administering naloxone every 3 to 4 hours is not necessary unless there are signs of narcotic overdose or respiratory depression.