# A 45-year-old client receiving IV morphine for postoperative pain develops generalized itching and a flushed face but no rash, no swelling, no wheeze, normal BP, and normal SpO2. The client and family are concerned this is an allergy. Which is the best nursing response?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375146&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 45-year-old client receiving IV morphine for postoperative pain develops generalized itching and a flushed face but no rash, no swelling, no wheeze, normal BP, and normal SpO2. The client and family are concerned this is an allergy. Which is the best nursing response?

## Option

1. Stop the morphine immediately and document a true morphine allergy in the chart.
2. This is most likely non-allergic histamine release that is common with morphine; consider diphenhydramine 25 mg IV, slow the infusion or switch to a synthetic opioid such as fentanyl or hydromorphone if the symptom persists, and continue to monitor for true allergic signs (urticaria with wheal, angioedema, bronchospasm, hypotension). **✔ Correct answer**
3. Tell the client this is normal pain and offer aspirin.
4. Increase the morphine dose to override the itching.

**Correct answer: 2**

## Explanation

Morphine and other natural opiates (codeine, meperidine) cause direct, non-immune histamine release from mast cells, producing pruritus, flushing, sweating, and hives without urticarial wheal, angioedema, bronchospasm, or hemodynamic compromise. This is not a true IgE-mediated allergy and does not generally require permanent avoidance, although it is uncomfortable. Distinguishing features: (1) non-allergic histamine release — symmetric pruritus, mild flushing, no airway/circulatory compromise, transient, does not progress; (2) true allergy — urticaria with raised wheals, angioedema, wheeze or stridor, hypotension, anaphylaxis, requires immediate epinephrine and permanent avoidance, label the chart, choose a structurally different opioid class. Management of histamine pruritus: diphenhydramine 25 to 50 mg PO/IV, slow IV infusion rate, switch to a synthetic opioid that releases little histamine (fentanyl, hydromorphone, oxycodone, methadone) when persistent. Permanently labeling allergy and giving aspirin are wrong; raising the dose worsens the histamine release.

## In-depth explanation

Pruritus alone with normal hemodynamics is histamine release, not allergy. Switch to fentanyl or hydromorphone if persistent, and reserve the allergy label for true urticaria-angioedema-wheeze-hypotension.

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