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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. While some clients with chronic pain may develop coping mechanisms, this does not mean that measures for relief are unnecessary. Pain management is still crucial for maintaining quality of life.
B. Opioid-based analgesics can be effective for some individuals with chronic pain, but their effectiveness can vary and they may not always be the best option due to potential side effects and the risk of dependence.
C. Chronic pain can be challenging to assess, but the perception and expression of pain are subjective and can vary greatly among individuals. Constant complaints of pain do not necessarily mean the pain intensity is difficult to assess; rather, it indicates the need for thorough pain evaluation.
D. Chronic pain often does not trigger the same physiological responses as acute pain. Therefore, vital signs such as heart rate, blood pressure, and pulse rate may remain normal even while the client is experiencing pain. This can make it more challenging to assess the presence and intensity of pain solely based on these parameters.

A. Apply petroleum jelly to the client's lips after oral care. B. Use the thumb and index finger to keep the client's mouth open. C. Use a stiff toothbrush to clean the client's teeth. D. Turn the client on his side before starting oral care.

Correct Answer is D

Explanation

A. Petroleum jelly can be applied, but it is not the priority action.
B. Using the thumb and index finger to keep the client's mouth open can be unsafe and uncomfortable.
C. A soft toothbrush should be used to prevent injury to the oral mucosa.
D. Turning the client on his side reduces the risk of aspiration during oral care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

Correct Answer is D

Explanation

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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