A nurse is caring for a patient who reports pain in his left leg that he rates as an 8 on a scale from 0 to 10 and states that he feels tingling and numbness in his toes.
The patient has an order for morphine sulfate 2 mg IV bolus PRN every two hours for pain greater than 7, last administered three hours ago, and ibuprofen 400 mg PO PRN every four hours for pain less than or equal to 7, last administered six hours ago.
What action should the nurse take first?
Administer morphine sulfate 2 mg IV bolus.
Administer ibuprofen 400 mg PO.
Assess the patient’s leg for circulation, sensation, and movement.
Reassess the patient’s pain in 15 minutes.
The Correct Answer is C
The correct answer is choice C. Assess the patient’s leg for circulation, sensation, and movement.
This is because the patient’s symptoms of pain, tingling, and numbness in his left leg could indicate a potential complication of impaired blood flow or nerve damage after surgery. The nurse should prioritize assessing the patient’s leg for any signs of compromised circulation, sensation, or movement before administering any pain medication.
Choice A is wrong because administering morphine sulfate 2 mg IV bolus without assessing the patient’s leg could mask the symptoms of a serious problem and delay appropriate interventions. Morphine sulfate is a potent opioid analgesic that can cause respiratory depression, sedation, and constipation.
Choice B is wrong because administering ibuprofen 400 mg PO without assessing the patient’s leg could also mask the symptoms of a serious problem and delay appropriate interventions. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, renal impairment, and increased risk of cardiovascular events.
Choice D is wrong because reassessing the patient’s pain in 15 minutes without assessing the patient’s leg could result in the worsening of the patient’s condition and increased risk of complications. The nurse should not delay assessing the patient’s leg for any signs of impaired circulation, sensation, or movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Check the client’s allergy history.
This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.
Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.
Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.
Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.
Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.
Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.
Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.
Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.
Correct Answer is D
Explanation
The correct answer is choice D. The patient will experience improved mental status and oxygenation.This is because naloxone is a medication that can rapidly reverse an opioid overdose by blocking the effects of opioids and restoring normal breathing.Naloxone can be given as a nasal spray or an injection.
Choice A is wrong because naloxone does not increase euphoria and sedation, but rather reverses them by blocking opioid receptors.
Choice B is wrong because naloxone does not cause severe withdrawal symptoms and agitation, but rather mild to moderate ones that are not life-threatening.
Choice C is wrong because naloxone does not decrease respiratory rate and blood pressure, but rather increases them by reversing opioid overdose.
Normal ranges for respiratory rate are 12 to 20 breaths per minute and for blood pressure are 90/60 mmHg to 120/80 mmHg.
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