A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 breaths/minute. The nurse prepares for which priority action at this time?
Assessment of the patient's pain level
Close observation of signs of opioid tolerance
Immediate intubation and artificial ventilation
Administration of naloxone
The Correct Answer is D
A. Assessment of the patient's pain level: While pain assessment is important, the patient's lethargy and shallow respirations indicate a potential opioid overdose, which takes priority.
B. Close observation of signs of opioid tolerance: The patient's symptoms are indicative of opioid overdose, not tolerance.
C. Immediate intubation and artificial ventilation: While respiratory support may eventually be necessary if the patient's condition deteriorates further, administering naloxone to reverse the opioid effects is the initial priority.
D. Administration of naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors, which can rapidly restore normal respiratory function and
consciousness in patients experiencing opioid-induced respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The last dose of medication should be given 4 to 6 hours before bedtime to diminish insomnia: Methylphenidate is a stimulant medication commonly used to treat ADHD.
Administering it at bedtime may interfere with sleep onset and lead to insomnia. It's important to follow the prescribed dosing schedule to optimize symptom control during waking hours while minimizing adverse effects on sleep.
B. The medication should be taken with meals for optimal absorption: While taking
methylphenidate with meals may help reduce gastrointestinal side effects, the timing of administration relative to bedtime is more relevant to address in this scenario.
C. The medication should not be taken until he is at school: Delaying medication until the child is at school may result in inadequate symptom control during the morning when ADHD
symptoms are often most problematic.
D. She is giving him the medication dosage appropriately: Administering methylphenidate at bedtime is not appropriate and may lead to insomnia rather than optimizing symptom control during the day.
Correct Answer is ["A","C","D","E"]
Explanation
A. Monitor the patient's respiratory rate: It's essential to monitor the patient for any adverse effects of morphine administration, particularly respiratory depression.
B. Ensure naloxone is readily available: While naloxone is an antidote for opioid overdose, administering it would depend on the patient's response and any signs of opioid toxicity, which may not be evident at this time.
C. Report the error to the facility through the proper paperwork: Reporting the medication error is crucial for documentation, investigation, and implementation of corrective actions.
D. Inform the patient's health care provider: The healthcare provider should be notified of the medication error to ensure appropriate follow-up and monitoring of the patient.
E. Document the dose of morphine given by the MedSurg nurse: Documenting the medication administration accurately is essential for the patient's medical record and continuity of care.
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