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.
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Related Questions
Correct Answer is D
Explanation
A. Consult the social worker to speak with the client about support groups. While a social worker can be a valuable resource, advocacy involves the nurse directly supporting the client rather than referring them to another professional as the primary action.
B. Help the client make decisions about their treatment by providing them with your opinions. Advocacy means ensuring the client has accurate, unbiased information to make informed decisions, not influencing them with personal opinions.
C. Provide the client with a computer to look up questions they have about their diagnosis. While access to information is important, the nurse should provide evidence-based resources and ensure the client receives accurate, professional guidance.
D. Avoid discussing alternative treatments that may have the potential to harm the client. Advocacy includes ensuring the client is aware of safe and effective treatment options while protecting them from misinformation or potentially harmful alternatives.
Correct Answer is B
Explanation
A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.
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