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 C
Explanation
A. Take the medication in the morning to prevent insomnia: This instruction is not directly
related to minimizing anticholinergic effects; it's more about managing the timing of medication administration.
B. Use cooling measures to decrease fever: Anticholinergic effects do not typically cause fever, so this instruction is not relevant.
C. Chew sugarless gum to moisten the mouth: Anticholinergic medications can cause dry mouth (xerostomia), and chewing gum can stimulate saliva production, alleviating this side effect.
D. Take an antacid to relieve nausea: Anticholinergic effects can include nausea, but taking an antacid is not a specific strategy for managing this side effect.
Correct Answer is ["0.6"]
Explanation
To find out how many milliliters (mL) of methylnaltrexone should be administered to achieve a dose of 12 mg, we need to set up a proportion based on the available concentration.
Given:
- Methylnaltrexone concentration: 8 mg per 0.4 mL
- Desired dose: 12 mg
We can set up the proportion as follows:
8 /0.4 = 12 / x
Where ( x ) is the unknown amount of methylnaltrexone in milliliters.
To solve for ( x ), we can cross multiply and then divide:
8x = 0.4 12
8x = 4.8
x = 4.8/8
x = 0.6
Therefore, the nurse should administer 0.6 mL of methylnaltrexone.
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