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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Increased heart rate: Sympathetic nervous system stimulation typically leads to increased heart rate as part of the "fight or flight" response.
B. Decrease in urinary bladder muscle tone: Sympathetic stimulation would typically cause relaxation of the urinary bladder, leading to increased muscle tone.
C. Increased blood pressure: Sympathetic nervous system activation results in vasoconstriction and increased cardiac output, leading to elevated blood pressure.
D. Decreased salivation: Sympathetic stimulation can lead to decreased salivation as part of the "fight or flight" response, but it's not a consistent finding.
E. Decreased bowel sounds: Sympathetic activation can inhibit gastrointestinal motility, leading to decreased bowel sounds, but it's not a universal finding in sympathetic stimulation.
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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