The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?
Assistance with endotracheal intubation
Administration of protamine sulfate
Administration of naloxone (Narcan)
Administration of oxygen
The Correct Answer is C
A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Stage II pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
B. Stage I pressure ulcers are characterized by intact skin with non-blanchable redness.
C. Stage III pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
D. Stage IV pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer is C
Explanation
A. The nurse should not inform the provider that the PCA is not providing adequate pain relief, as this is not true based on the client's pain rating of 2 out of 10.
B. The nurse should not ask the provider for a prescription to decrease the continuous rate, as this may compromise the client's pain relief and comfort.
C. The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects.
D. Instructing the caregiver to push the button without the client's request may lead to overmedication and potential respiratory depression.
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