The client is a 42-year-old female who had a right above-the- knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What actions should the nurse take to assure safety morphine administration? Select all that apply.
Suction the client to clear the airway
Restrain the client with soft restraints
Perform a 12-lead electrocardiogram
Have a manual resuscitation bag at the bedside
Ask the client about other medications she takes
Take an initial respiratory rate
Correct Answer : E,F
A. Suctioning the client to clear the airway is not directly related to the administration of morphine and is typically not a routine precaution unless the patient has a specific need.
B. Using soft restraints is not a standard safety measure for morphine administration and could be considered if the patient has a history of confusion or agitation, but there is no such indication in this scenario.
C. Performing a 12-lead electrocardiogram is not a standard procedure for ensuring the safe administration of morphine and is usually done for cardiac assessment.
D. Having a manual resuscitation bag at the bedside is a good practice in case of an emergency but is not specific to morphine administration safety.
E. Asking the client about other medications she takes is crucial to prevent drug interactions, as morphine can interact with many medications, potentially leading to adverse effects.
F. Taking an initial respiratory rate is important because morphine can cause respiratory depression, and it is essential to have a baseline to monitor for any changes after administration.
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Related Questions
Correct Answer is D
Explanation
A. Explaining that the dosage has been changed is not appropriate without confirming the accuracy of the prescription.
B. Telling him to take the medication and verifying the dosage later could result in harm if the dosage is incorrect.
C. Informing him that he may refuse the medication is an option, but it does not address the potential error in dosage.
D. Withholding the medication until the dosage can be confirmed is the safest action to prevent potential medication errors
Correct Answer is D
Explanation
A. Initiate seizure precautions: Dopamine administration does not typically require seizure
precautions. The focus should be on monitoring for adverse effects related to blood pressure and urinary output.
B. Monitor serum potassium frequently: While electrolyte imbalances can occur with dopamine administration, the priority is to monitor urinary output as dopamine affects renal perfusion and urine output.
C. Assess pupillary response to light hourly: Monitoring pupillary response is important in some situations, but it's not the primary concern with dopamine administration.
D. Measure urinary output every hour: Correct! Dopamine is administered to improve renal perfusion and increase urine output in hypotensive patients. Monitoring urinary output every
hour is essential to assess the effectiveness of dopamine therapy and detect any signs of renal dysfunction or worsening hypotension.
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