The MedSurg nurse assesses a patient after arriving on the unit from the PACU. The patient states that she is in pain, rating the pain at a 7 out of 10. The nurse administers 4mg morphine IV as prescribed. After administering the drug, the PACU nurse calls to say a dose of morphine was given and not documented. What actions should the nurse perform? (Select all that apply) (Select All that Apply.)

Monitor the patient's respiratory rate

Ensure naloxone is readily available

Report the error to the facility through the proper paperwork

Inform the patient's health care provider

Document the dose of morphine given by the MedSurg nurse

Answer and Explanation

Correct Answer : A,C,D,E

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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. The patient's respiratory rate: Morphine sulfate is an opioid analgesic that can cause

respiratory depression as a side effect. Therefore, assessing the patient's respiratory rate is crucial before administering the medication to ensure it is within normal limits.
B. The appearance of the incision: While assessing the incision is important for overall surgical site assessment, it's not directly related to the administration of morphine sulfate.
C. The date of the patient's last bowel movement: Bowel movements may be impacted by anesthesia and surgery, but they are not directly relevant to assessing the safety of administering morphine sulfate.
D. The patient's pulse rate: Pulse rate is important for overall assessment of the patient's

condition but may not directly indicate the need for or safety of administering morphine sulfate.

A. Dantrolene injection, a skeletal muscle relaxant B. Cardiopulmonary resuscitation (CPR) and intubation C. An anticholinesterase drug, such as neostigmine D. Naltrexone hydrochloride injection, an opioid reversal drug

Correct Answer is A

Explanation

A. Dantrolene injection, a skeletal muscle relaxant: The patient is exhibiting signs of malignant hyperthermia, a potentially life-threatening complication of anesthesia. Dantrolene is the primary treatment for malignant hyperthermia as it acts as a skeletal muscle relaxant, reducing muscle rigidity and hypermetabolism associated with the condition.
B. Cardiopulmonary resuscitation (CPR) and intubation: While the patient is experiencing significant physiological distress, initiating CPR and intubation would be premature without first addressing the underlying cause, which appears to be malignant hyperthermia.
C. An anticholinesterase drug, such as neostigmine: Anticholinesterase drugs like neostigmine are not indicated for the treatment of malignant hyperthermia.
D. Naltrexone hydrochloride injection, an opioid reversal drug: Naltrexone is used for opioid overdose reversal and is not appropriate for the treatment of malignant hyperthermia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient?

Correct Answer is A

Explanation

During the immediate postoperative period, the Post Anesthesia Care Unit nurse is assessing a patient who had hip surgery. The patient is experiencing tachycardia, tachypnea, and muscle rigidity, and his temperature is 103°F (39.4°C). The nurse will prepare for what immediate treatment?

Correct Answer is A

Explanation

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. Available is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

While being intubated, a client with a head injury experienced bradycardia. Atropine was consequently administered. What assessment should be postponed until all atropine is excreted and no longer exerting an effect?

A patient has been treated with antiparkinson medications for 3 months. What therapeutic responses should the nurse look for when assessing this patient?

When assessing patients in the preoperative area, the nurse knows that which patient is at a higher risk for an altered response to anesthesia

The nurse is caring for a 64-year-old male client with diabetes who is being treated with a nonselective beta-blocker. What health education should the nurse prioritize with this client?

A patient has been taking ergotamine to relieve their migraines. Which of the following adverse effects would indicate to the nurse that the drug may have entered into toxic levels?