A nurse caring for a client who has a prescription for morphine 5 mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
Report the incident to the pharmacy.
Notify the client's provider.
Measure the client's respiratory rate.
Complete an incident report.
The Correct Answer is C
A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
Correct Answer is D
Explanation
A. Enlarged adenoids Enlarged adenoids may contribute to airway obstruction, especially in children, but they are not a complication of OSA.
B. Diabetes mellitus While OSA is associated with an increased risk of insulin resistance and metabolic syndrome, it is not a direct complication.
C. Nasal polyps Nasal polyps can contribute to breathing difficulties but are not a complication of OSA.
D. Heart failure OSA can lead to chronic hypoxia and increased cardiac workload, contributing to conditions such as hypertension, arrhythmias, and heart failure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.