A client receiving intravenous morphine reports itching and facial flushing. Blood pressure and respirations are stable, and there are no wheals, angioedema, or wheezing. Which action should the nurse take?
1Assess airway and vital signs, notify the prescriber, and treat likely histamine-related itching as ordered.✓ Correct answer
2Record a permanent morphine allergy and avoid every opioid because itching alone confirms anaphylaxis.
3Increase the morphine rate because itching indicates that the current dose is not relieving pain.
4Ignore the symptom because morphine-related itching cannot progress or require treatment.
Explanation
Morphine can release histamine and cause pruritus or flushing without true anaphylaxis. The nurse should assess the airway and vital signs, notify the prescriber, provide ordered treatment, and continue monitoring for urticaria, angioedema, wheezing, or hypotension. Itching alone does not justify increasing the opioid or automatically labeling every opioid as an allergy.
Clinical reasoning Morphine-associated histamine release can produce itching and flushing. Stable breathing and circulation without angioedema, wheezing, or hypotension make immediate anaphylaxis less likely, but continued assessment remains essential.
Decision rule Assess first, notify the prescriber, and use ordered symptom treatment while watching for progression. A true allergy label should be based on the full reaction pattern, not pruritus alone.