A nurse caring for a client who has a prescription for morphine 5 mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
Report the incident to the pharmacy.
Notify the client's provider.
Measure the client's respiratory rate.
Complete an incident report.
The Correct Answer is C
A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Place the bell of the stethoscope on the client's chest." The diaphragm of the stethoscope, not the bell, should be used to auscultate breath sounds because it is designed for high-pitched sounds like lung sounds.
B. "Follow a systematic pattern from side-to-side moving down the client's chest." To accurately compare breath sounds bilaterally, the nurse should use a side-to-side pattern, moving down the chest and back. This ensures a proper assessment of any asymmetry or abnormal sounds.
C. "Ask the client to breathe in deeply through his nose." The client should be instructed to breathe deeply through their mouth, not their nose, to enhance the clarity of breath sounds.
D. "Instruct the client to sit erect with their head tilted slightly backward." The ideal position for auscultating lung sounds is sitting upright with shoulders relaxed and slightly forward, allowing full lung expansion. Tilting the head backward is unnecessary.
Correct Answer is C
Explanation
A. "The food is not great, but it is nice not having to do all of my own cooking." This statement shows acceptance by acknowledging both the challenges and benefits of the transition.
B. "When I go out, I've been using public transportation since I can't drive anymore." This reflects adaptation to the changes by finding alternative transportation.
C. "I don't want to go to the activity room because none of the other residents can hear." This suggests social withdrawal and frustration, which may indicate difficulty accepting the transition to assisted living.
D. "The staff sometimes have to remind me to use a cane when I walk in the hall." This shows acceptance of help from staff, which suggests an adjustment to the new environment rather than resistance.
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