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 ["15"]
Explanation
Given:
Amantadine syrup concentration: 50 mg/5 mL Desired dose of amantadine: 150 mg
5ml contains 50mg
1ml contains 50/5= 10mg Given 10mg is in 1ml
Then 150mg will be contained in: 150/10
=15ml
Correct Answer is C
Explanation
A. These are adverse effects that usually subside after a few weeks: While some adverse effects of phenobarbital may diminish over time, the symptoms described by the patient are more likely related to its impact on REM sleep.
B. The drug must be stopped immediately because of possible adverse effects: Stopping phenobarbital abruptly can lead to withdrawal symptoms and potential rebound seizures; discontinuation should be done gradually under medical supervision.
C. This drug causes deprivation of REM sleep and may cause the inability to deal with normal stress: Phenobarbital is known to disrupt REM sleep, leading to emotional lability, irritability, and difficulty coping with stress.
D. This drug causes the rapid eye movement (REM) sleep period to increase, resulting in nightmares and restlessness: Phenobarbital actually decreases REM sleep, which can lead to disturbances in sleep patterns and mood changes.
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