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. Chronic grief Chronic grief is prolonged and intense, lasting for an extended period without resolution. The client's symptoms suggest a different grief response.
B. Masked grief Masked grief occurs when a person experiences physical symptoms or maladaptive behaviors that they may not initially recognize as being related to their loss. The client's headaches, indigestion, and heart palpitations are physical manifestations of their grief.
C. Exaggerated grief Exaggerated grief involves intense emotions and self-destructive behaviors, such as depression, substance abuse, or suicidal thoughts, rather than primarily physical symptoms.
D. Delayed grief Delayed grief occurs when a person suppresses their emotions and does not experience grief reactions until later, often triggered by another event. The client's current physical symptoms suggest an ongoing response rather than a delayed one.
Correct Answer is A
Explanation
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
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