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 B
Explanation
A. Signs of bone marrow depression are not typically associated with antiepileptic drugs. This adverse effect is more commonly seen with medications such as chemotherapy agents.
B. Increased risk of suicidal thoughts and behaviors is a well-documented concern with antiepileptic drugs, particularly when used for psychiatric indications or in certain patient populations. The FDA has issued warnings regarding this risk, and healthcare providers should monitor patients for changes in mood, behavior, and suicidal ideation.
C. While some antiepileptic drugs may have cardiovascular effects, such as prolongation of the QT interval, the FDA warning specifically highlights the risk of suicidal thoughts and behaviors rather than cardiovascular events like strokes.
D. Indications of drug addiction and dependency are not typically associated with antiepileptic drugs. These medications are not central nervous system depressants and do not produce the euphoria or withdrawal symptoms characteristic of addictive substances.
Correct Answer is A
Explanation
A. The benefit to eating frequent small meals during the day: Nonselective beta-blockers can mask symptoms of hypoglycemia, making it harder for patients with diabetes to recognize low
blood sugar levels. Eating frequent small meals can help stabilize blood sugar levels and reduce the risk of hypoglycemia.
B. Perform more frequent blood glucose checks due to effects of the drug: While it's important for patients with diabetes to monitor their blood glucose levels regularly, this instruction doesn't directly address the potential masking of hypoglycemia symptoms by beta-blockers.
C. The need to weight himself once per week at the same time of the day: Weight monitoring is important for overall health management but is not specifically related to the use of nonselective beta-blockers in diabetes management.
D. The correct method for taking their own apical pulse: Knowing how to take one's own apical pulse is important for some individuals, but it's not directly related to the management of
diabetes with nonselective beta-blockers.
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